Last name | ............................................................. | |
First name | ............................................................. | |
Title (Prof./Dr./Mr./Mrs./Ms.) .......................... | ALP Membership number .................... | |
Affiliation | ............................................................. | |
Address | ............................................................. | |
City | ............................................................. | Zip/Postal Code .................... |
Country | ............................................................. | |
Telephone | ............................................................. | Fax............................................................. |
............................................................. |
ILPS conference fee | ....................... U.S. Dollars |
Additional banquet tickets ......... x 50 U.S. Dollars = | ....................... U.S. Dollars |
Workshop fee (for non-ILPS participants only .....) | ....................... U.S. Dollars |
Total | ....................... U.S. Dollars |
Special dietary requests: Vegetarian [ ] Kosher [ ]
Payment of registration fees can be done through VISA or MASTERCARD (with faxed or surface mailed signed forms), bankers drafts, money orders, bank checks or electronic bank transfers. If cancellation is received by September 10, 1997 a 75 percent refund will be given. There will no refunds for cancellations received afterwards.
Credit card payees must add another 7% to the total.
[ ] Credit card registration (to be faxed or sent by surface mail)
Type (please circle one) VISA MASTERCARD
Card Number ......................................................................
Expiration Date ........................
Name as it appears on the card ...........................
Amount (Total + .07 x Total)........................ U.S. Dollars
Authorized Signature .....................
[ ] Electronic Bank transfer (by email or to be faxed or sent by surface mail)
Prof./Dr./Mr./Mrs./Ms. ....................................
has remitted the total of ................... U.S. Dollars
through (bank name) ..............................................
to this account:
Account name: ILPS97
Account number: 921187807
Routing number: 021410080
Name of Bank: Marine Midland Bank, 300 Main Street, Suite 1, East Setauket, NY 11733
Please make sure that ALL bank charges are at the participant's expense.
[ ] A bankers draft, money order, bank check amounting to .............U.S. Dollars is enclosed
(to be faxed or sent by surface mail)
Please make sure that the check is payable to the above mentioned
account (i.e., ILPS97), and that bank charges are at the participant's expense.
Date: ....................................... | Signature: ....................................... |