REGISTRATION FORM

INTA/USPTO ROUNDTABLES

March 14, 2013

Please type or print:�Mr. �Mrs. �Ms.

First Name Last Name Job Title Company/Firm

Street Address City State Country Zip Postal Code

Telephone Facsimile Email Address

LOCATION

Kilpatrick Townsend & Stockton LLP1100 Peachtree St NE, Suite 2800Atlanta, Georgia 30309-4528

DATE

Thursday, March 14, 2013Lunch: 12:00 pmDiscussion: 12:30 pm–2:30 pm

Registration Fee

The registration fee is US $45.00�RGT�RGTUQP�RGT�UGUUKQP�CPF�KPENWFGU�C�DWHHGV�OGCN��6JG�HGG�KU�PQPTGHWPFCDNG�WRQP�EQPƁTOCVKQP�QH�VJKU� registration by INTA. If you are unable to attend, you may send a substitute.

The roundtable will be limited to WZHQW\�ÀYH������CVVGPFGGU��CPF�TGUGTXCVKQPU�CTG�CEEGRVGF�QP�C�ƁTUV�EQOG��ƁTUV�UGTXGF�DCUKU��7RQP�TGCEJKPI�capacity, a waiting list will be created. If a seat becomes available, you will be contacted immediately. All registrations must be made no later WKDQ�����GD\V�EHIRUH�WKH�VFKHGXOHG�URXQGWDEOH. All roundtable registrants must be pre-registered; WKHUH�ZLOO�EH�QR�RQVLWH�UHJLVWUDWLRQV. Registra-tion by mail is not preferred.

Payment

To secure your reservation, please fax your registration with credit card information to the International Trademark Association, ����������������6Q�EQPƁTO�[QWT�TGIKUVTCVKQP��RNGCUG�EQPVCEV�VJG�%WUVQOGT�5GTXKEG�&GRCTVOGPV�CV�customerservice@inta.org.

The only acceptable method of payment is by credit card. � American Express � Discover �MasterCard � Visa

Name as it appears on credit card

Card Number Expiration Date CVV#*

Signature

* The CVV# Secure code is a 3 or 4 digit code printed on your credit card. We require this code as a security measure to our customers to ensure that the credit ECTF�KU�RTGUGPV�CV�VJG�VKOG�QH�RWTEJCUG��+H�[QW�ECPPQV�ƁPF�VJKU�EQFG��QT�KV�KU�KNNGIKDNG��RNGCUG�EQPVCEV�[QWT�ETGFKV�ECTF�KUUWGT� Visa, Mastercard and Discover Cards: The Secure code is the 3 digit value printed on the signature panel located on the back of your card. It is the last 3 numbers in that area. American Express Cards: The Secure code is the 4 digit value printed (not-embossed) above your account number on the front of your card. CLE CLE credits are not offered for roundtables. You can apply for CLE credits individually from your state bar.