First name:
Last name:
Affiliation:
Address:
Home or Business:
City:
State:
Zip or postal code:
Country:
Daytime telephone:
Net address:
Early
Postmarked by September 30, 1996)
Regular: $400
Student: $200
Banquet: $ 60
(Students must send legible proof of full-time student status.)
Late (Postmarked after September 30, 1996)
Regular: $450
Student: $240
Banquet: $ 60
(Students must send legible proof of full-time student status.)
TOTAL FEE:
(Please enter correct amount.)
Check
Mastercard
VISA
American Express
Money Order
Credit card number
Expiration date
Name (as it appears on card)
Signature
Please mail completed form with your payment to
or fax with credit card information to 415/321-4457. Please Note: Requests for refunds must be received in writing by 15 October 1996. No refunds will be granted after that date. A $25.00 processing fee will be levied on all refunds granted.
Amount
Received