Registrations MUST be received by May 7th 2003.

Please print this form and mail to: Laura Reiner, Goldfarb Library, Mail Stop 045, Brandeis University Libraries, 415 South Street, Waltham, MA 02454-9110

Name (please print or type) ___________________________________________________________________


Affliation (for name badge) ___________________________________________________________________


Email _____________________________________


Check one:

___ ASIST member: $25.00

___ Student/retiree/between jobs: $15.00

___ Spouse/significant other of ASIST member: $15.00

___ Non-ASIST member: $35.00


Entree choices (check one):

__ Chicken Provencal Sauté Chicken Breast with Tomatoes, Shallots, Garlic, Herbs & Black Olives

__ Grilled Marinated Vegetable Kabobs Southwestern Corn Salad with Basmati Pinenut Rice Pilaf (Vegetarian)

Payment:

___ By check: make out check to "NEASIST"

___ By credit card:

Credit card type (circle one): --- Mastercard --- Visa --- American Express ---

Credit card number: _____________________________________________

Expiration date: __________________

Name on credit card: ____________________________________________

Signature: _____________________________________________________

(Please copy form after signing, if you would like a receipt.)