Printable Registration Form

Also available as a PDF registration form. 

Name:____________________________________________________________
     
Affiliation:_____________________________________________________
     
Address:_________________________________________________________
          
City:_______________________________ State/Province:_____________
     
Country:_______________________ Zip/Postal Code:_________________

Phone:____________________ E-mail:_______________________________

REGISTRATION FEE (must be received by February 12, 2007)

[ ] $250.00 US   Conference March 5-7 
                 (Meeting materials, some meals and reception)

[ ] $300.00 US   Conference Tradeshow Exhibitor
                 (8-foot table space)
				 
[ ] $550.00 US   Workshop March 8-10 
                 (Lunches and dinners, but no on-site housing)

[ ] $700.00 US   Workshop March 8-10 
                 (On-site housing and all meals)

$ __________ Total amount enclosed
    
PAYMENT

  [ ] Check payable to Alaska Sea Grant enclosed
        
  [ ] Charge my VISA or MasterCard account

Card number: _____________________________________ V code: _______

Exp. date:_____________ Printed name:_____________________________
     
Signature:________________________________________________________ 

CREDIT CARD BILLING ADDRESS (if different from above)

Address:__________________________________________________________

City:_______________________________ State/Province:______________
     
Country:___________________________ Zip Code:_____________________

Please fax or mail form to:

Conference Coordinator
Alaska Sea Grant College Program
PO Box 755040
Fairbanks, AK 99775-5040 USA
Fax: (907) 474-6285