CONFERENCE REGISTRATION FORM
					Thursday, May 24, 2001
					        Release 1.2

				         REGISTRATION DEADLINE:
				             Friday, January 25th, 2002

To be considered for a scholarship, you must fill out the Scholarship Registration Form instead of this Conference Registration Form.

REGISTRATION DEADLINE
The conference registration deadline is Friday, January 25th, 2002.  All fees must be received by that date.  There is a late registration fee of $15 for general registrations, and a $5 late registration fee for community organizations, students, and low-income individuals after this date for registration at-the-door on the day of the conference.

SUBMITTING THE REGISTRATION FORM
1. Print or download this form, fill it out as clearly and completely as possible, then mail or fax to:
	Genetics Conference Registration
	c/o WE ACT
	271 West 125th Street, Suite 308
	New York, New York 10027

	Fax #: (212) 961-1015

You may also register online to expedite the process.  All payments must be received in full before the registration deadline in order to complete the registration process.  See below for payment information.

Please e-mail any registration questions to conference@weact.org, or leave a voice mail on the conference hotline at (212) 961-1000, ext. 333.  For more information, please visit the conference website at www.weact.org/conference.

2. Send your registration fees as a check or money order payable to "WE ACT," and mail to the following address:
	Genetics Conference Registration
	c/o WE ACT
	271 West 125th Street, Suite 308
	New York, New York 10027

REGISTRATION IS NOT COMPLETE UNTIL
YOUR FEES HAVE BEEN RECEIVED


PERSONAL INFORMATION (Please Print Clearly)

Prefix: _____________________________________________________________________
(i.e. Mr., Ms., Dr., Prof., Reverend)

First Name: _________________________________________________________________

Middle Name: _______________________________________________________________

Last Name: _________________________________________________________________

Suffix: _____________________________________________________________________
(i.e. Jr., III., M.D., Ph.D., Esq.)

Organization / Company: _______________________________________________________

Department: __________________________________________________________________

Job Title: _____________________________________________________________________


CONTACT INFORMATION (Please Print Clearly)

Select One:
	(  ) Work Address
	(  ) Home Address
	(  ) Home Office Address
	(  ) Other: (please specify) ______________________________________________

Bldg. Name: __________________________________________________________________

Address(1): ___________________________________________________________________

Address(2): ___________________________________________________________________

Apartment/Suite/Room/Floor: ____________________________________________________
(Specify: "Apt. 5B", "Ste. 303", "Rm. 317", "3rd. Fl.")

City: _________________________________________________________________________
(Please Spell Out, i.e. New York)

State: ________________________________________________________________________
(Please Spell Out, i.e. New York)

ZIP(r) Code: ___________________________________________________________________
(Specify: ZIP+4 if desired. Format: 10027-4424)

Country: ______________________________________________________________________
(Abbreviate if Necessary, i.e. USA)

Voice Phone: ______________________________  Ext.: ______________________________
(Format: (212) 961-1000, Ext. 307)

Fax: _________________________________________________________________________
(Format: (212) 961-1000)

E-Mail: _______________________________________________________________________
(Format: Carlos@weact.org)

Website: http://_________________________________________________________________

Notes:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________


REGISTRATION PAYMENTS (Please Print Clearly)

Early Registration Fee
	(  )	$50.00	General Registrants
	(  )	$25.00	Community Organizations, Student, and Low-Income Participants
		(Must include a brief explanation on organizational letterhead, or a copy of student ID when mailing)

Late Registration Fee (At-the-Door)
	(  )	$65.00	General Registrant
	(  )	$30.00	Community Organizations, Student, and Low-Income Participants
		(Must supply a brief explanation on organizational letterhead, or a copy of student ID)

Voluntary Contribution to help fund a scholarship
	Amount: $


Payment Enclosed
	(  )	Personal Check	Check No: _______________ Amount: ______________
	(  )	Money Order	Order No: ________________ Amount: ______________


SPECIFIC REQUIREMENTS (Please Print Clearly)
	(  ) I would like to request the use of equipment for Spanish translation during the conference.

	Please specify any special needs:
	Dietary Requirements:
	______________________________________________________________________
	______________________________________________________________________
	______________________________________________________________________
	______________________________________________________________________
	Disability Access / Needs:
	______________________________________________________________________
	______________________________________________________________________
	______________________________________________________________________
	______________________________________________________________________

	I heard about this conference through...
		(  ) WE ACT mailing
		(  ) WE ACT e-mail
		(  ) WE ACT website
		(  ) A friend / colleague
		(  ) Other: (please specify) _______________________________________