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Contact
Information
Name: _________________________________________________________
Organizational Affiliation (for your badge): ___________________________
Address: _______________________________________________________
City: ___________________________________ Zip/Postal Code: ______________
State:_____________
Country:_________ Email:_______________________________
Phone: ___________________________________ Fax: ___________________________________
How did
you hear about this conference?___________________________________
___Do not
include my contact information on the attendee list.
Payment
Information
Make checks
payable to Alcor. Checks and bank drafts must be in U.S. dollars drawn on a
U.S. bank.
Name as it
appears on credit card:_______________________________________________________
Credit card
number(VISA/MC/AMEX):______________________________________________________
Expiration
date:__________________________
Print then
fill out this form and fax or mail to Alcor. A separate form is required
for each person attending the conference.
Or register by phone by calling Alcor at 800-482-6791
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