Please complete the form below by entering your response(s) within the brackets [ ] following the prompts. Use "X" to indicate a selection. Once completed, you may E-mail this form to jmerryman@agu.org (TIP: COPY/PASTE BLANK FORM INTO E-MAIL DOC.) or fax it to the attention of Johanna Merryman at +1-202-328-0566.
Name: [ ]
Badge Name: [ ]
Address: [ ] (use semi-colons to separate lines of the address)
City: [ ]
State/Prov.: [ ]
Zip/FPC: [ ]
Country: [ ]
Phone: [ ]
Fax: [ ]
E-mail: [ ] (must be included in order to receive a confirmation)
REGISTRATION FEES: There are no one-day or prorated registration
fees. Participant registration fees cover admission to all oral and
poster sessions, admission to the Opening Reception, refreshment
breaks, and the Conference Dinner.
[ ] Professionals $ 235.00
[ ] Students $ 115.00
FIELD TRIP INFORMATION:
[ ] Yes, I am interested in receiving additional information about
the field trip to Lake Bonneville shorelines and Stansbury Island,
Great Salt Lake. This field trip is scheduled to take place on
Friday, June 19.
GUEST EVENT TICKETS: Guests of registered attendees, must purchase
tickets to the events they wish to attend:
[ ] Guest Reception ticket $17.00 x [ ] tickets
[ ] Guest Banquet ticket $35.00 x [ ] tickets
Name of Guest [ ]
PAYMENT INFORMATION: Payment, in U.S. currency, must accompany
this form.
TOTAL AMOUNT ENCLOSED
Registration: [ $ ]
Guest Reception tickets [ $ ]
Guest Banquet tickets [ $ ]
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Total Amount Due: [ $ ]
[ ] American Express
[ ] Visa
[ ] Mastercard
Cardholder's Name: [ ]
Card Account Number: [ ]
Expiration Date: [ ]
Billing ZipCode/FPC: [ ]
SPECIAL REQUESTS Please indicate any special requests, needs or
restrictions, such as disabilities, or dietary restrictions. An AGU
staff person will contact you with ways that we can accommodate you.
[ ]