Society for Light Treatment and Biological Rhythms

13^th Annual Meeting, June 24-27, 2001

Nobel Forum, Karolinska Institute, Stockholm, Sweden

Meeting and CME Course Registration Form

One registration form for each participant. Please type or print clearly. Mailed, faxed or emailed registrations will be accepted through June 8, 2001. After that date, registration will be accepted on-site only.

Name: _____________________________________________________________________________

First Last Suffix

Title: ______________________________________________________________________________

Affiliation: _________________________________________________________________________

Address: ___________________________________________________________________________

City: __________________________ State: ____________________ Zip: ____________________

Country: ___________________________________________________________________________

Telephone: ________________________________Fax: _____________________________________

Email: _____________________________________________________________________________

Annual Meeting Fees

Corporate Member $600.00

SLTBR Member $135.00

Non-member $220.00

Student $ 70.00

Banquet (per person) $ 80.00

(please make selection)

○ Veal

○ Fish

○ Vegetarian

CME Course Fee $75.00
(ALL are welcome to attend the CME course, but there is an additional course fee)

Late registration fee $25.00

Total $_______

___ Enclosed is my check payable to SLTBR

___ Charge registration fees to my credit card

___ MasterCard ___ Visa

Card Number: _________________________

Expiration Date: ________________________

Name of Cardholder: ____________________

Signature ______________________________

Society for Light Treatment and Biological Rhythms

PO Box 591687, San Francisco, CA, USA 94159-1687

TEL (415) 876-0716 · FAX (415) 751-2758

email: sltbrinfo@aol.com