Registrations MUST be received by May 20th 2005.

Please print this form and mail to: Caryn L. Anderson, P.O. Box 788, Jamaica Plain, MA 02130.
Questions about registration: carynlanderson@yahoo.com

Name (please print or type) ___________________________________________________________________


Affiliation (for name badge) ___________________________________________________________________


Email _____________________________________


Check one:

___ ASIST member: $30.00

___ Spouse/significant other of ASIST member: $20.00

___ Student/Retiree/Between Jobs: $20.00

___ Non-ASIST member: $40.00


Choice of Dinner Entrée (check one):

__ Grilled Portobello Napoleon Layered with Roasted Tomatoes and Fresh Mozzarella served with Pan Roasted Potato Gnocchi and Crispy Spinach.

__ Spinach and Pancetta Stuffed Chicken with Madeira Jus served with Creamy Polenta and Slow Roasted Plum Tomatoes.

Payment Information (Check or Credit Card):

___ By check: (Please make checks payable to NEASIST and mail together with registration form)

___ By credit card:

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

Name on credit card: ____________________________________________

Credit card number: _____________________________________________

Expiration date: __________________


Signature: _____________________________________________________

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