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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