Name (please print or type) ____________________________________________________________  
          
      
Affliation (for name badge) ___________________________________________________________________
      
      
Email: ____________________________________________
      
      
Check one:
___ ASIS Member:  $55.00

___ non-members:  $65.00

___ student/retiree/between jobs:  $25.00

 

      
Make out check to "NEASIS."   
Or, charge my credit card: ___ Mastercard     ___ Visa     ___ American Express

Number ___________________________________________  Expiration date: __________________

Signature  ____________________________________________________________________________

registrations MUST be received by May 5        

Please print this form and mail to:

Dick Luxner/ PO Box 277/ Stowe, MA 01775

(please copy form for additional registrations)