Non-Member RegistrationFNHMA 2019 National Conference Fairmont Queen Elizabeth Hotel Tuesday, November 5 to Thursday, November 7, 2019 1. Participant InformationAre you a Certified First Nations Health Manager (CFNHM):YesNoBase Price Price: $ 965.00 CAD Quantity: Name* First Name: Last Name: Title:Organization:Division:Email:* Phone:*Address:* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth KoreaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe 2. Registration FeesEarly-Bird Rate $910 (Your registration form and payment must be received by September 27, 2019) Regular Rate: $965 (as of September 28, 2019)Early Bird RateEarly Bird RateYour registration form and payment must be received by September 27, 2019 to get the early bird rate. Regular RateRegular RateDate Reception and Banquet ticket for a guest:*You may purchase a ticket for a guest for the Reception and Banquet on Tuesday, November 6.None - $ 0.00 CAD1 Guest - $125.00 CADName of Guest:*Are you GST exempt?*NoYesNote: The conference is being held in Quebec where 5% GST applies.The FNHMA HST/GST number is 811344852. If your Indian band is GST/HST exempt, please upload a copy of the band’s exemption certificate or letter by clicking “choose file” button to find and upload your certification or letter in digital form (only .JPG, .PNG, .PDF accepted). Note: an individual’s personal status card is not an accepted document for tax exemption for the conference.Certificate or letter File Upload*Accepted file types: jpg, jpeg, png, pdf.3. PaymentPlease Choose Your Payment Method*Pay by Credit CardPay by ChequeFNHMA only accepts Visa, Mastercard, or chequeSubtotal $ 0.00 CAD Add 5% GST $ 0.00 CAD Total $ 0.00 CAD Credit Card* MasterCardVisa Card Number Month010203040506070809101112 Year20202021202220232024202520262027202820292030203120322033203420352036203720382039 Expiration Date Security Code Cardholder Name 4. CancellationCANCELLATION / SUBSTITUTION*Please email your cancellation to email@example.com. Cancellations will be accepted until October 4, 2019 for a full refund. A $300 cancellation fee will apply for cancellations received between October 5 and October 18, 2019. There is no refund for cancellations received after October 18, 2019 and no refund for no-shows at the conference. Substitutions are accepted at any time. I agree to the Cancellation / Substitution Policy. Confirmation ID Number This iframe contains the logic required to handle AJAX powered Gravity Forms.