3rd Annual Conference of Specialized Centers in Neuroscience
Excellence in Neuroscience at Minority Institutions
May 27-29, 2003
Waikiki Beach Marriott Resort
Honolulu, Hawai'i

 

Receipt deadline for late registration: March 31, 2003
GENERAL REGISTRATION FORM
 (Submit one form per individual SNRP attendee. * indicates required information.)

Preferred Title:

*First Name: Middle Initial: *Last Name:

*Degree(s): B.A.   B.S.   M.S.   M.D.   Ph.D.   Other   If Other, specify:

Position/Title:

*Institutional Affiliation:

*Mailing Address:
 
*City: *State: *Zipcode:

*Phone: FAX:

*Email:

*Relationship to SNRP:  If Other, specify:

SNRP Investigators: Check this box if you are interested in attending a pre-conference workshop on "Innovations in Neuroscience Techniques" (May 27, 2003):

Please indicate which airline carrier you will use to travel to Hawaii (select only one):

REGISTRATION FEES

Conference Registration Fee:   $425

Special Meal Requirement (Vegetarian):

Tickets for Spouses/Guests

Spouse/Guest Name(s):
Number Guests Requiring Special Meals (Vegetarian):

All dollar amounts will be automatically calculated.

Note that the Conference Registration Fee (for SNRP attendees) includes the Opening Reception Dinner, all meals and breaks. The next four lines are to specify additional meals for Spouses and Guests.

Tuesday Opening Reception (5/27/03): guest tickets @$54.00 $
Wednesday Luncheon (5/28/03): guest tickets @$27.00 $
Wednesday Dinner (5/28/03): guest tickets @$54.00 $
Thursday Lunch (5/29/03): guest tickets @$32.00 $

Total Fees Enclosed: $


PAYMENT INFORMATION

*Form of Payment:
Check made payable to Research Corporation of the University of Hawaii
I hereby authorize the Research Corporation of the University of Hawaii the use of my credit card account for this conference registration.

If paying by credit card, please complete the information below.

*Credit Card Type: VISA MasterCard
For security reasons, please provide only the first 12 digits of your credit card number. After you have submitted your form, call us toll-free at 800-913-SNRP (800-913-7677) to provide the last 4 digits of your credit card number. If you leave a telephone message, be sure to include your full name so we can properly identify your registration information.
*First 12 Digits of Credit Card Number:  
*Expiration Date:  /   
*Name on Card:
*Billing Address:
*Telephone: