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_US_registrants.

EARLY_BIRD_DISCOUNT_-_Register_before_July_1,_2013_and_take_10%_off_Registration_or_Package_Price

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) Early Bird Eligible

$________

□ 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) Early Bird Eligible

$________

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

Early Bird Eligible $________

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

$________

□ 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) $________ If received by July 1, 2013, deduct 10% from Registration Fee or Package Price

Total Amount Due: $________

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

$100.00 [__] Person(s) $________