On-Line Registration Form

In order to submit a registration request to the Technology Transfer Center, please complete all REQUIRED fields. Those marked with a ** are not required.

Workshop Information
Workshop Title:
Workshop Location:
Workshop Date(s): / / **
Select Session
Applicant Name:
Title:
Agency/Municipality/Other:
Mailing Address
Address 1:
Address 2:
City:
State:
Postal/Zip Code:
Work Phone:
Fax#:
*Email address: (required)
Billing Information (phone & address are required)
Full Name:
Billing Email Address:
Billing Contact Phone#:
Address 1:
Address 2:
City:
State:
Postal/Zip Code:

* Confirmation receipt will be sent to this address and IS REQUIRED. If you do not supply confirmation email address, your registration will not be processed and will generate an error page.

If you have a special dietary restriction or need special accommodations, please contact Shelly Desjardin, our Program Assistant, at (860) 486-9373.

Registration Fee Payment

By Check To be sent by Mail
Purchase Order
        (enter #):
ConnDOT Voucher
        (enter #):
Total Due:

Payment is due prior to the date of the workshop. If paying by check, please make payable to UConn and mail to:

Connecticut Transportation Institute
Attn: Carolyn Ward
179 Middle Turnpike, Unit 5202
Storrs, CT 06269-5202

BEFORE submitting...PRINT or "SAVE AS..." a copy of this registration for your records.
Be sure you have entered ALL information requested.

A confirmation of your registration will be sent to you soon.

Cancellation Policy: The registration fee is refundable if notice of cancellation is received 48 hours prior to the start of the program. Registrants who are unable to attend and do not cancel in advance are subject to the registration fee. Substitutions may be made at any time. Please notify us of changes.

 

 

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