RECOMB'97 REGISTRATION FORM

Prof  /  Dr  /  Mr  /  Ms  /  Mrs (circle one)

Name ________________________________________________________________
Last                            First                           MI

I would like my name tag to read _____________________________________________

Affiliation/Business ______________________________________________________

Address ______________________________________________________

City ______________________________________________________

State ___________________    Zip ________________________

Country_____________________________________________

Citizenship_____________________________________________

Telephone (include area code)

Business _______________________________     

Home______________________________ 

Email ____________________________

Fax (include area code) _______________________

Please circle one category below and fill in your membership number
if appropriate: #____________________________

Category                          Fee   After 12/20 (extended deadline)
------------------------------------------------------------------
ACM 				  285   360
Other                             360   435
Student                           160   210
Extra Banquet Tickets _____ x $50 each = _______________________

Total Registration _____________________________________________

 We are sorry but we do not accept credit cards. 

Dietary restrictions:  Kosher______  Vegetarian______  None_____

Special needs (attach letter if necessary):