DGM SYPMPOSIUM- MAY 24-26, 1999, NEWPORT, RI
RESISTRATION FORM
________________________________________________
Name
________________________________________________
Affiliation/Department
________________________________________________
Address
________________________________________________
CITY/STATE/ZIP
________________________________________________
PHONE/FAX/EMAIL
DORMITORY RESERVATION:
SINGLE $66.00 per night ______ DOUBLE $76.00 per/night ______ MALE/FEMALE ______
Indicate name of roommate for double (if you want to be randomly assigned a roommate, leave blank and submit payment for one person only)
NAME OF ROOMMATE: _________________________________________________
REGISTRATION FEES:
With Proceedings $125.00
Student $ 25.00
Dormitory $ 66.00 per night (single)
$ 76.00 per night (double)
TOTAL ____________
MAKE CHECK PAYABLE IN US DOLLARS TO BROWN UNIVERSITY
CREDIT CARD: VISA _____ MASTERCARD_____ AMERICAN EXPRESS ____
NUMBER:______________________________EXP:____________________________
SIGNATURE____________________________________________________________