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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
   Prefix:	(i.e. Mr., Ms., Dr., Prof., Reverend)
   First Name:
   Middle Name:
   Last Name:
   Suffix:	(i.e. Jr., III., M.D., Ph.D., Esq.)
   Org./Company:
   Department:
   Job Title:

   CONTACT INFORMATION
   Address Type:	Work Home Home Office      If "Other," please specify:
   Bldg. Name:
   Address(1):
   Address(2):
   Apt/Ste/Rm/Fl:	(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® 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 Line:	(Format: (212) 961-1000)
   E-Mail:	(Format: Carlos@weact.org)
   Website:
   Notes:

   REGISTRATION PAYMENTS
   Regular Registration:	$50.00 for General Registrants $25.00 for Community Organizations, Student, and Low-Income Participants (Must supply a brief explanation on organizational letterhead, or a copy of student ID at the door)
   Voluntary Contribution:	I would like to provide a voluntary contribution in the amount of $ to help fund a scholarship.
   Payment Enclosed:	Personal Check Check No.: Amount: Money Order Order No.: Amount:

   SPECIFIC REQUIREMENTS

   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 first heard about this conference through... WE ACT Mailing WE ACT E-Mail WE ACT Website A Friend / Colleague If "Other," please specify below:

   

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