Name (please print or type) ____________________________________________________________  
      
      
ASIS member no. ___________
      
      
Affliation/Institute ___________________________________________________________________
      
      
Address: _______________________________________________________________________________
      
      
Telephone: ________________________  Email: ____________________________________________
      
      
Please check the workshop you wish to attend ___ 19 July (Mon.) ____ 21 July (Wed.)
      
      
Remember to enclose your check for $35.00, payable to "NEASIS." One name per
form. Registration is limited to 12 people each day, and is non-refundable.
      
      
        

Please print this form and mail to:

Jonah Jay Jenkins
1259 Cambridge St. #2
Cambridge, MA 02139