May 2007 IAB Registration Form

May 2007 IAB Registration Form

PLEASE REMEMBER TO LOG OUT WHEN YOUR VISIT TO THE MEMBERS ONLY SECTION IS COMPLETE

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