University of the Virgin Islands 
Caribbean Exploratory Research Center 10th Annual Health Disparities Institute 
St Thomas, USVI — October 18-20, 2017 
Frenchman’s Reef & Marriott Beach Resort 
INSTRUCTIONS: Complete this Registration Payment Form and email or post it to: Dr. Gloria B Callwood, Director — 
Caribbean Exploratory Research Center University of the Virgin Islands, 2 John Brewers Bay, US Virgin Islands 00801 
Download, complete and save this PDF to your computer then attach it to an email addressed to:  CERCSecretariat@uvi.edu 
Title:
Prof.
Dr.
Mr.
Mrs.
Ms.
Other:
Full Name:
University/Organization Name:
University/Organization Address:
Email Address:
Mobile Phone Number:
Presenter
Non-Presenter
Registration Type
USVI Residents
General
Student
Amount USD
Early-Bird On or Before Sept. 18, 2017
$250
$325
$125
Pre-Registration On or Before Oct. 6, 2017
$275
$375
$175
On-Site Registration
$300
$400
$175
Day Rate
$150
$225
$100
Undergrads
Graduates
Professionals
Pre-Institute Workshop Registration
$20
$30
$50
TOTAL:
PAYMENT METHODS AND INSTRUCTIONS (Cash is not accepted)
Check One
Payment by Money Order or Bank Check (Not Personal Check): Make payable to "CERC — University of the Virgin 
Islands." Mail to the above address, together with this Registration Payment Form. Note: Please email a scanned 
copy of the check to the Director before mailing the original. You will receive a receipt via email.
Payment by Credit Card by Email: Complete the information required below and email this Registration Payment 
Form to the Director to forward to the UVI Cashier for processing. You will receive a receipt via email.
Payment by Credit Card by phone: Call the UVI Cashier’s office directly for them to take the credit card details over 
the phone. 340-693-1437 or Mr. Robert Chen at 340-693-1143.  State it is for Conference Fees for the CERC 
Institute Account No. 260239, and provide your name and email address.  You will receive a receipt via email. 
Note: You still need to complete and email this Registration Payment Form to the Director (but only enter the last 
four digits of the credit card number).
UVI Faculty/Staff Members: Name of
School/College paying your Registration Fees
Dean’s Signature
Date:
PLEASE CHARGE MY:     MASTERCARD
VISA
NAME ON CARD:
                                                     CARD NUMBER:
EXPIRATION:
3-DIGIT SECURITY CODE:
$0.00
Enter date as MM/YYYY