Workshop Registration Form (Print Version)
Due to the capacity of available facilities, Registration will be limited. Registrations must be received by July 12, 2004. The registration fee includes the Reception and Dinner on August 5, 2004 and a CD of the Workshop Highlights. Lunches are not included in the Registration Fee and are available in the adjacent BNL cafeteria.
All fields below are mandatory and must be completed unless they are marked as optional. Please submit one per registrant. If you need assistance, contact Susan Walch (walch@bnl.gov). Print out the form and FAX or Mail your registration information to us.
| Meeting Coordinator: Susan Walch Phone: 631-344-2418 FAX: 631-344-7905 Email: walch@bnl.gov Web: www.bnl.gov/srog |
Address: c/o Susan Walch Brookhaven National Laboratory Bldg 815/526 Upton, NY, 11973-5000 U.S.A. |
|
| Personal Information: | ||
| Preferred Title (optional) | ___ Prof ___ Dr. ___ Mr. ___ Mrs. ___ Ms. | |
| First Name | ________________________________________________________ | |
| M.I | _______ | |
| Last Name | ________________________________________________________ | |
| Citizenship | ||
| Affiliation | ||
| Name on your Workshop Badge | ________________________________________________________ | |
| Phone Number | ___________________________ | |
| Fax Number (optional) | ___________________________ | |
| Email Address | _____________________________________ | |
| (confirmation will be sent to this address) | ||
| Mailing Information | ||
| Address | ________________________________________________________ | |
| City | _____________________________________ | |
| State/Province | _____________________________________ | |
| Postal Code | _____________________________________ | |
| Country | _____________________________________ | |
| Break Out Session Registration | ||
|
___
Session A - Gas Futures ___ Session B - Unconventional Reservoirs ___ Session C - Heavy Oil Futures |
||
| Payment Method | ||
|
Registration received without payment
will not be processed. Checks
are made payable to Brookhaven Science Associates or BSA.
All payment must be made in U.S. dollars with Foreign Exchange
fees added for non U.S. Banks. Bank Wire Transfers are
Not Accepted. Registration Fee: $50.00 Guest Dinner Ticket (optional): $35.00 Total: __________ Select Payment Method: ____ U.S. Check ____ Credit Card |
||
| For Check Payments: Make checks payable to: Brookhaven Science Associates or BSA Reference "SROG Workshop" on bottom of check and send to: c/o Susan Walch Brookhaven National Laboratory Bldg 815/526 Upton, NY, 11973-5000 U.S.A. All payments must be done by July 12, 2004 |
||
| For Credit Card Payments:
(All information is kept confidential.) Card Type: ____ Visa ____ MasterCard ____ American Express _____________________________________________________ Name (exactly as it appears on card) _______________________________ Card Number _______________________________ Expiration Date All payments must be done by July 12, 2004 |
||
|
|
||
| Comments: (optional) | ||
|
________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ |
||
Please
Do Not submit your registration more than once.