Registration Form

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

Phone:____________________ E-mail:_______________________________

REGISTRATION FEE (check appropriate amount):

  [ ] $165.00 US through April 25  [ ] $190.00 US after April 25

  $________ Registration

  $________ Donation to Wakefield Endowment

  $________ Total
    
PAYMENT

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

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