Conference Registration Form
for the 18th Annual Meeting of the
Society for Light Treatment and Biological Rhythms
(SLTBR)
July 13 – 15, 2006
Please submit one registration form for each participant. Please type or print clearly. Mailed or faxed registrations will be accepted through June 15. After June 15, a $25 late fee will be added.
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Name: ________________________________________________________________________________ |
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Title: __________________________________________________________________________ |
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Affiliation: _______________________________________________________________________________ |
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Address: _______________________________________________________________________________ |
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City: _________________________________ State/Province ____________ Zip: _________ |
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Country: _______________________________________________________________________ |
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Telephone: _______________________________Fax: _________________________________ |
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Email: ________________________________________________________________________ |
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(Registration confirmation
will be sent via email.) |
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Annual Meeting Fees ($US ) |
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______ Charge registration fees to my credit
card |
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[ ] SLTBR Member $150.00 |
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[ ] Non-member $225.00 |
______ MasterCard ______ Visa |
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Student
$ 75.00 |
Card Number: |
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[ ] Corporate Exhibitor $700.00 |
______________________________________ |
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Late registration fee (after June
15) $25.00 |
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Expiration Date:
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Total $US_______________ |
Name of Cardholder: |
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______________________________________ |
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___ Enclosed is my check ( $US ) payable to
SLTBR |
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Check
number: _______________________________ |
Signature |
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