Name (please print or type) ____________________________________________________________  
      
      
ASIS member no. ___________ (if member)
      
      
Affliation  ___________________________________________________________________
      
      
Email: ____________________________________________
      
      
Check one:
___ ASIS Member:  $30.00
___ non-member:   $50.00


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

Number ___________________________________________  Expiration date: __________________

Signature  ____________________________________________________________________________    

registrations MUST be received by July 27         

Please print this form and mail to:

Jonah Jenkins / Rotch Library / Room 7-238 / MIT / 77 Mass. Ave. / Cambridge, MA 02139

(please copy form for additional registrations)