CONFERENCE REGISTRATION REFUND ALLOCATION FORM

CONFERENCE REGISTRATION REFUND ALLOCATION FORM

Due to unforeseen circumstances all future conferences have been cancelled. Please complete this form prior to November 15, 2022 to avoid delays in your refund allocation.
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Conference year originally registered for:Type year here*
Registration fee paid:
Type total fee paid here*
Conference Refund Allocation*

I wish to donate my full conference registration fee to the refund pool, so that others may be refunded in a quicker manner.I wish to apply my full conference registration fee to my future CIM exam fee. This option does not have an expiration date and the exam can take place anytime in the future. The exam fee is currently higher that all refund amounts and you will not owe any further exam fees if you choose this option.I wish to donate my full conference registration fee to be used as a CIM exam fee, for a Midwife student in need, that is living and working solely in a high risk, low resource setting.I wish to receive a full refund of my original conference registration fees paid. I acknowledge the refund will be paid to me in monthly installments and the monthly payments will be arranged by a legal mediator. Monthly refund installments will begin approximately December 28, 2022 and will be paid on approximately the 28th of each month after, until full repayment has been made. If the 28th falls on a weekend or holiday, the payment will be sent via my chosen method, on the following business day. I acknowledge that I will need to complete a subsequent form where I will choose how to receive my monthly refund installments. I acknowledge that I will be required to sign and return the forthcoming written repayment method agreement, prior to the commencement of payments. Please note: If this form is returned after November 15, 2022, there will be a delay in the commencement of monthly payments and payments will begin approximately 8 weeks after we receive this completed form and your forthcoming signed repayment method agreement.
Signature*

Clear
Should be Empty: