CONFERENCE REGISTRATION

Name:
(Dr.) (Mr.) (Ms.) (Mrs.)

 ____________________________________________________
Organization ___________________________________________________________________
Address:  
Street: _________________________________________________Unit/Apt___________
City _________________________________State________Zip___________________
Day Phone (____)__________________________, Extension____________
Evening Phone (____)__________________________
Fax (____)__________________________
E-Mail _______________________________@__________________________________

Full Conference $300.00 ($250.00 if paid before June 15, 2004)

Make Checks payable to IBMBS

Mail Registration and Payments to International Behavioral & Medical Biometrics Society:

9534 14th Ave., NW
Seattle, WA 98117-2308
   

VISA MASTERCARD PAYMENTS

Account Name
[as it appears on your card]


__________________________________

Account Address
[if different from above]

  
Street: _________________________________________________Unit/Apt___________
City

_________________________________________________Unit/Apt___________
   


Visa/ Mastercard

16 number account number __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
Expiration Date


(Month) (Year) ___________________________
Authorized Signature ______________________________________
Check:  
   
   

FOR MORE INFORMATION:

Web Site: www.ibmbs.com or www.ibmbs.org

E-mail to registration@ibmbs.com

Write:

I.B.M.B.S.
9534 14th Ave NW
Seattle, WA 98117-2308, U.S.A.

Call (206) 783 3410 or Fax (206) 784 2206
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