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CONFERENCE REGISTRATION FORM v1.0

Download the Registration Form in Microsoft Word Format. (28KB)

Download the Registration Form in Adobe Acrobat Format. (14KB).
     This option requires the free Adobe Acrobat Reader (8.6MB).

Download the Registration Form in a Simple Text Format. (4KB)

Download all three formats of the Registration Form as a WinZip compressed archive. (17KB)

REGISTRATION DEADLINE:
Friday, January 25th, 2002

REGISTRATION DEADLINE
The conference registration deadline is Friday, January 25th, 2002. All fees after this date must be paid at-the-door. Please do not mail in your payment after this date. The late registration dues are $65 for general registrations, and $30 for community organizations, students, and low-income individuals. After this date you must register 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
    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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for Regional Environmental Justice (CUCREJ)

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Copyright © 1998-2007. All Rights Reserved.
Web Manager: Carlos M. Jusino
Content Manager: Swati R. Prakash

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