Registration Form

Name:____________________________________________________________
     
Affiliation:_____________________________________________________
     
Address:_________________________________________________________
          
City:_______________________________ State/Province:_____________
     
Country:_______________________ Zip/Postal Code:_________________

Phone:____________________ E-mail:_______________________________

REGISTRATION FEE (check appropriate amount):

[ ] $160.00 until October 1        [ ] $200.00 after October 1
    
PAYMENT

  [ ] Check payable to University of Alaska Sea Grant enclosed
      for total of $__________
        
  [ ] Charge my VISA or MasterCard account for $__________

Card number: __________________________________ Expires: ________

Signature:______________________Printed Name:____________________
     

Alaska Sea Grant College Program, University of Alaska Fairbanks
P.O. Box 755040, Fairbanks, AK 99775-5040 USA
Fax: (907) 474-6285