Symposium Registration Form (Registration Deadline: May 1, 2002)

Return form with payment to:
UIC Conferences and Institutes (MC 265)
322 South Green Street, Suite 212, Chicago, IL 60607-3544
Fax: (00)1-312-996-5227 (credit card payment only)

3rd International Symposium on Serpin Biology, Structure and Function
June 2-5, 2002, Chicago

A separate form should be completed for each registrant. For security purposes, please do not submit credit card information via Internet.

Last Name First Name Middle Initial

Title

Agency/Organization/Institution

Department/Division

Mailing Address: (check one): Home Office

Street Address Room Number/Mail Code (if applicable)

City State

Country Postal Code

Phone Fax

E-mail

Special Accommodation/Dietary Requirements (please specify):

PAYMENT INFORMATION

 

PAYMENT METHOD

Registration Fee:

$     475

Check or Money Order
        (payable to University of Illinois)

Accompanying Guest Tickets:

Credit Card:  MasterCard     Visa

Monday night dinner
        June 3 (venue to be announced)

# @ $25 = $

 

Card Number

Wednesday night banquet
        June 5, Shedd Aquarium

# @ $50 = $

Expiration Date

Total Amount Enclosed:

$

Cardholder's Signature __________________