NAME(S): ___________________________________________________________________________________________

ADDRESS: __________________________________________________________________________________________

CITY: ____________________________STATE/PROV: _______ ZIP/POSTAL CODE: ____________ COUNTRY: ______________

PHONE: ______________________________________ EMAIL ADDRESS: _________________________________________

PREFERRED NAME(S) FOR YOUR BADGE(S): (1) _______________________ (2) ________________________

FIRST TIME ATTENDEE? YES _____ NO _____All prices quoted in U.S. dollars and are per person, unless otherwise noted. Spouses or partners are

considered members for registration purposes. Tax deduction shown is amount allowed for U.S. registrants.

rEGisTraTion ForM

ChUrChill PErsPECTivEs on lEaDErshiP30th INtERNAtIONAL ChURChILL CONFERENCE - OCtOBER 31 - NOVEMBER 2, 2013

For late registration (after October 1), please add $50 per registrant.

Checks should be made payable to “The Churchill Centre” and sent with this form to the address below, or FAX or phone Visa/MasterCard/Discover/American Express information:

Card Number: _______________________________________Exp. Date:____________________ CVS Code ________________________

Authorized Signature: ___________________________ Print name exactly as it appears on the card: _________________________________

If your credit card billing address is different from the address on top of registration form, please include billing address here: _______________________

____________________________________________________________________________________________________________

PLEASE NOTE: You may also register online by going to the secure server at http://bit.ly/14Hiaf1.

THE CHURCHILL CENTREP.O. Box 945, Downers Grove, IL 60515-0945

Toll Free: 888-WSC-1874 • Local Phone: 630-512-9341 • FAX: 630-515-1123WWW.WINSTONCHURCHILL.ORG

□ Chartwell Club Package (US Tax deduction: $1,103 couple/$442 single) Includes Welcome Reception, 2 luncheons, Special VIP Reception, Friday and Saturday dinners with special seating, tickets for two optional tours and student underwriting.

$3,000 couple $1,500 single

[__] Person(s) $________

□ Blenheim Club Package (US Tax deduction: $940 couple /$360 single) Includes Welcome Reception, 2 luncheons, Saturday Gala Dinner, tickets for two optional tours .and student underwriting

$2,500 couple $1,250 single

[__] Person(s) $________

Following are Individual Ticket Prices if Purchased Separately □ Basic Registration – Member $475.00 [__] Person(s) $________

□ Basic Registration – Non-member (Includes one year membership) $600.00 [__] Person(s) $________

□ Friday Dinner and Reception (cash bar) $145.00 [__] Person(s) $________ □ Saturday Black-tie Gala Dinner and Reception $195.00 [__] Person(s) $________ □ National Cryptologic Museum Tour (Thursday) $90.00 [__] Person(s) $________ □ Dodona Manor Tour (Thursday) $70.00 [__] Person(s) $________ □ Washington By Night Tour (Thursday evening after reception) $40.00 [__] Person(s) $________

Following are Single-Day Tickets for Locals Unable to Register for Whole Conference □ Thursday (Includes evening Welcome Reception) $75.00 [__] Person(s) $________ □ Friday sessions (Includes Luncheon, but not dinner) $225.00 [__] Person(s) $________ □ Saturday sessions (Includes Luncheon, but not dinner) $225.00 [__] Person(s) $________

Total Amount Due: $________

□ Special Teacher Registration – Teachers at secondary, high school or college level; includes all sessions and luncheons.

$100.00 [__] Person(s) $________