May 2007 IAB Registration Form

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IAB Registration Form (Please Type or Print)

NOTE: A registration form is required for each person attending the IAB. Please print this page, fill out the form and fax it to Susan at the address below.

Name:

Name for Badge:

Title:

Company:

Mailing Address:

City/State/Zip:

Phone:

Fax:

E-mail:

URL:

Assistant’s Name:

Assistant’s Phone:

Assistant’s Email:

If you have special dietary needs, please provide a brief description.

*Are you a speaker? Yes___________ No_______________

*Speakers please provide and abstract and list of audio-visual equipment needs and return it with your registration.

Please contact Susan at the address below with any questions or for more detailed information.

Susan C. Charnley, CLPAM Secretary

E-mail: unikorn@umich.edu
Phone: 734-647-6824
Fax: 734-763-5772