Registrations MUST be received by April 5th 2001.

Please print this form and mail to: Laura Reiner, NEASIS Registration, MIT Rotch Library Room 7-238, 77 Massachusetts Avenue, Cambridge, MA 02139

      
Name (please print or type) ___________________________________________________________________  
          
      
Affliation (for name badge) ___________________________________________________________________
      
      
Email (please provide, for confirmation of registration): _____________________________________
      
      
Check one:

___ ASIS member:  $30.00

___ Non-members:  $40.00

___ Student/retiree/between jobs:  $20.00

___ Spouse/significant other of ASIST member:  $20.00


Entree choices (check one:

___  Chicken Piedmont (chicken breast, fresh herbs, sundried tomatoes, and romano cheese)

___  Grilled atlantic salmon (garlic, lime, and shallot buerre blanc)

___  Tomato cous cous risotto with fresh herbs roasted corn salad & wild mushroom ragout


Payment:
      
___  By check: make out check to "NEASIS" and mail check with registration form.   

___  By credit card: 

      Credit card type (i.e. Mastercard, etc.): _____________________________________  

      Credit card number: _____________________________________________  

      Expiration date: __________________

      Name on credit card: ____________________________________________

      Signature:  _____________________________________________________

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