Conference & CME Course Registration Form

for the 1st Joint Meeting of

the Society for Light Treatment and Biological Rhythms (SLTBR) &

the American Association of Medical Chronobiology

and Chronotherapeutics (AAMCC)

May 28 – 30, 2004

Toronto, Canada

 

Please submit one registration form for each participant.  Please type or print clearly. Mailed or faxed registrations will be accepted through May 15. After May 15, a $25 late fee will be added.

 

Name:   ________________________________________________________________________________

          First                                                            Last                                                              Suffix

 

Title:   __________________________________________________________________________

 

Affiliation:   ________________________________________________________________________________

 

Address:   ________________________________________________________________________________

 

City:   _________________________________  State/Province   ____________ Zip:   _________

 

Country:   _______________________________________________________________________________

 

Telephone:  _______________________________Fax:   _________________________________

 

Email:    ________________________________________________________________________

(Registration confirmation will be sent via email.)

 

 

Annual Meeting Fees ( $US )

___ Enclosed is my check ( $US ) payable to SLTBR

 

 

[   ]  SLTBR or AAMCC Member                      $150.00

Check number:  _______________________________

[   ]  Non-member                                               $200.00

 

[   ]  Student                                                        $  70.00

______   Charge registration fees to my credit card

[   ]  Corporate Exhibitor                                    $700.00

 

 

              ______   MasterCard              ______   Visa

[   ]  Banquet                                                        $ 50.00

 

CIRCLE: BEEF, FISH, VEGETARIAN

Card Number:

[   ]  CME Course Fee ($US)                                     

            ______________________________________

[  ]   Conference Registrant                                 $ 50.00

 

[   ]   Student Registrant                                       $ 25.00

Expiration Date:

            ______________________________________

[   ]  Non-conference registrant                          $100.00

 

 

Name of Cardholder:

[   ]  Late registration fee (after May 15)              $ 25.00

            ______________________________________

 

 

 

Signature

 

            ______________________________________

Total                                                $US_______________

 

 

PO Box 591687 · San Francisco, CA  USA  94159-1687 · (415) 876-0716 · FAX (415) 751-2758

email: sltbrinfo@aol.com