Name: _______________________________________________________________________

Badge Name: ______________________________________________________________________

Address: _______________________________________________________________________

_______________________________________________________________________

City: ___________________ State/Province: ________ Zip/Postal Code: ________________

Country: ___________________

Phone: ___________________ Fax: __________________ E-mail: ______________________

Guest(S): __________________________ _____________________________________
 

REGISTRATION FEES: There are no one-day registration fees. Participant registration fees cover admission to all scientific sessions, refreshments, reception, and conference dinner. Please check off the appropriate registration box:

[ ] Scientists $ 245.00

[ ] Students $ 140.00
 

EXTRA TICKETS: Tickets must be purchased for guests who wish to attend these events.

[ ] Reception $20.00 each x ____ tickets = ____

[ ] Banquet $50.00 each x ____ tickets = ____
 

TOTAL AMOUNT ENCLOSED (Registration Fee plus Tickets for Guest): $________

PAYMENT INFORMATION: Payment in U.S. dollars must accompany this form.

[ ] Check (payable to AGU) OR

[ ] AMEX [ ] VISA [ ] Mastercard

Cardholder's Name: _______________________________________________________________

Card No.: _______________________________________________ Exp. Date:_______________

Signature: _______________________________________________________________(regform.txt)

Please indicate any special requests, needs, or restrictions, such as disabilities, or dietary restrictions.