Name of program
Mr./Ms./etc.
First Name
Middle Initial
Last Name
Organization
Title
Department
Address 1
Address 2
City
State
Zip Code
Country
Telephone
Fax
E-Mail
Citizenship (Country)
If not citizen of USA:	Are you a permanent resident?  Yes or No
Special Requests" (e.g. Arrangements for dietary needs, etc)
Fee Amount
Method of Payment:     (note all payments must include registrant's name and course name.
	CheckPayable to Research Foundation Award 27061
	Purchase Order           PO #
	Credit Card  (VISA or MasterCard only) Until further notice please call our office for a secure credit card transaction.   888-691-1465 or 607-777-2154