1998 REGISTRATION FORM

REGISTRATION FORM

39^th Teratology Society Annual Meeting
June 29 - July 4, 1999 Keystone, Colorado

For Office Use Only
Date Received:______
Input: _____ Initials_____

Member Non-Member (Please check the appropriate box)

Please print or type:
Name:

Affiliation:
Is this a new employer Yes No

Department:

Street Address:

City/State/Zip/Country:
Is this a new address Yes No

Telephone Number:

E-mail Address:
FAX Number:

I require the following special accommodations for accessibility:

REGISTRATION FEES (Until May 24):

Full Attendance: Single-Day Attendance:

Member: $320.00 $_______ Member: $125.00 $_______

Graduate Student / Post-doctoral
Fellow - Member / Non-Member:
(please circle one)
$190.00
$_______ Graduate Student / Post-doctoral Fellow - Member / Non-Member: (please circle one)
$ 50.00
$_______

Non-Member: $445.00* $_______ Non-Member: $175.00* $_______

Accompanying Adult: $225.00 $_______

Child Fee (under 12): $125.00 $_______

Name of Accompanying Person(s)

* Includes first-year membership dues if an application is submitted with registration or during the meeting and is acceptable

CONTINUING EDUCATION COURSE (Until May 24):

Member: $230.00 $_______
THERE IS A $20.00 CHARGE FOR CANCELLATION OF THE CONTINUING EDUCATION COURSE BEFORE May 24, 1999.
NO REFUNDS AFTER May 24, 1999.

Non-Member: $280.00 $_______

Graduate Student / Post-doc: $ $_______

TOTAL REGISTRATION FEE DUE:
$_______________

DEADLINE FOR ADVANCE REGISTRATION: MAY 24, DEADLINE FOR PRE-REGISTRATION: JUNE 1,1999

(After June 1, you must register on-site. On-site Registration Forms will be available at the Registration Desk.)

METHOD OF PAYMENT:

PLEASE make all checks or credit card charges payable to the TERATOLOGY SOCIETY in U.S. DOLLARS.

Check or Money Order #:
MasterCard (16 digits) Visa(13 or 16 digits)

Government Purchase Order #:
(Government P.O. Form MUST BE ATTACHED)

Credit Card #:

Expiration Date:________________________________

Signature:_____________________________________________ Cardholder's
Printed Name:_________________________________

If cardholder is different from registrant, please include cardholder's telephone number: (_____) _______________________

Mail completed form with remittance to:

TERATOLOGY SOCIETY, MEETING REGISTRATION, 1821 Michael Faraday Drive, Suite 300, RESTON, VIRGINIA 20190.
FAX (Credit Card Payments ONLY): (703) 438-3113. Government Purchase Orders may NOT be FAXED, they must be mailed with the registration form. Printed from http://teratology.org/forms/99register.html

REGISTRATION FORM
39^th Teratology Society Annual Meeting June 29 - July 4, 1999 Keystone, Colorado	For Office Use Only Date Received:______ Input: _____ Initials_____

Member Non-Member (Please check the appropriate box)

Please print or type: Name:
Affiliation:		Is this a new employer Yes No
Department:
Street Address:
City/State/Zip/Country:		Is this a new address Yes No
Telephone Number:
E-mail Address:	FAX Number:

REGISTRATION FEES (Until May 24):
Full Attendance:			Single-Day Attendance:
Member:	$320.00	$_______	Member:	$125.00	$_______
Graduate Student / Post-doctoral Fellow - Member / Non-Member: (please circle one)	$190.00	$_______	Graduate Student / Post-doctoral Fellow - Member / Non-Member: (please circle one)	$ 50.00	$_______
Non-Member:	$445.00*	$_______	Non-Member:	$175.00*	$_______
Accompanying Adult:	$225.00	$_______
Child Fee (under 12):	$125.00	$_______
			Name of Accompanying Person(s)
* Includes first-year membership dues if an application is submitted with registration or during the meeting and is acceptable

*CONTINUING EDUCATION COURSE (Until May 24):*
Member:	$230.00	$_______	THERE IS A $20.00 CHARGE FOR CANCELLATION OF THE CONTINUING EDUCATION COURSE BEFORE May 24, 1999. NO REFUNDS AFTER May 24, 1999.
Non-Member:	$280.00	$_______
Graduate Student / Post-doc:	$	$_______

TOTAL REGISTRATION FEE DUE:	$_______________		DEADLINE FOR ADVANCE REGISTRATION: MAY 24, DEADLINE FOR PRE-REGISTRATION: JUNE 1,1999
			(After June 1, you must register on-site. On-site Registration Forms will be available at the Registration Desk.)

METHOD OF PAYMENT:
PLEASE make all checks or credit card charges payable to the TERATOLOGY SOCIETY in U.S. DOLLARS.
Check or Money Order #:			MasterCard (16 digits) Visa(13 or 16 digits)
Government Purchase Order #:			(Government P.O. Form MUST BE ATTACHED)
Credit Card #:			Expiration Date:________________________________
Signature:_____________________________________________			Cardholder's Printed Name:_________________________________
If cardholder is different from registrant, please include cardholder's telephone number: (_____) _______________________

Mail completed form with remittance to: TERATOLOGY SOCIETY, MEETING REGISTRATION, 1821 Michael Faraday Drive, Suite 300, RESTON, VIRGINIA 20190. FAX (Credit Card Payments ONLY): (703) 438-3113. Government Purchase Orders may NOT be FAXED, they must be mailed with the registration form. Printed from http://teratology.org/forms/99register.html