To register, complete this form and send with payment by July 13, 1998. Registration is limited to 180 participants. If this meeting is oversubscribed, applicants will be selected based on information provided on this application form (below). Registration forms will be accepted only by mail or fax.
NAME __________________________________________________________
COMPANY/INSTITUTION _________________________________________
ADDRESS _______________________________________________________ ADDRESS _______________________________________________________
CITY, STATE, ZIP, COUNTRY _____________________________________
Phone (including area code) ______________________
Fax (including area code) ________________________
e-mail _______________________________________
SELECTION OF PARTICIPANTS: In the event of oversubscription, participants will be selected using criteria similar to those used by the Gordon Research Conferences.
For this reason, all applicants must provide the following information with their applications.
A) I work in a/an: (please select one of the following) | | Academic Institution | | Government Agency | | Industrial Corporation B) My role in this conference is : (please select one of the following) | | Speaker | | Discussion Leader | | Poster Presenter | | Attendee C) My position is : (please select one of the following) | | Graduate Student | | Postdoc | | Granting Agency Representative | | Professor | | Research Scientist | | Research Director | | Program Manager | | Other ______________
A) I work in a/an: (please select one of the following)
| | Academic Institution
| | Government Agency
| | Industrial Corporation
B) My role in this conference is : (please select one of the following)
| | Speaker
| | Discussion Leader
| | Poster Presenter
| | Attendee
C) My position is : (please select one of the following)
| | Graduate Student
| | Postdoc
| | Granting Agency Representative
| | Professor
| | Research Scientist
| | Research Director
| | Program Manager
| | Other ______________
Are you personally involved in research activities in the subject area of this conference? | | Yes | | No How many papers have you published during the last 3 years in the subject area of the conference? __________ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Indicate your particular activities which justify favorable consideration of you as a participant and contributor to this conference.
| | Yes | | No
Indicate your particular activities which justify favorable consideration of you as a participant and contributor to this conference.
CONFERENCE REGISTRATION: (Check one)
| | Full Registration $250 | | Student Registration $100 | | After July 13, 1998 $350
STUDENTS: A person working in a degree program up to and including the Ph.D. or postdoctoral fellows may register at the student rate. Student registration is NOT intended for those taking courses in addition to full-time employment. Please supply name of Ph.D. or postdoctoral advisor. __________________________
CANCELLATIONS: To cover the cost of handling the processing, $30 will be deducted from the total refund for cancellations. Requests for refunds must be postmarked or e-mailed on or before July 13, 1998.
FOOD AND LODGING: Includes three nights accommodation at the Golden Inn, breakfasts and luncheons, welcoming buffet dinner reception on Sunday October 4 and banquet dinner on Tuesday, October 6.
Please indicate:
$400 | | *Single Occupancy *NOTE: Single occupancy is limited
$290 | | Double Occupancy (per person)
Please Indicate (for housing purposes): | | Male | | Female
Name of Roommate (please print) : ___________________________________
Enter Food And Lodging Costs: $ __________________
A special lodging-only rate of $100 per night per room will be extended for early arrivals and $82 per night per room for extended stays. Please indicate your requirements for early arrival and/or extended stay lodging.
List extra dates required (early arrival and/or extended stay) ________________________________
Enter early arrival and/or extended stay amount: $_____________
Enter Registration fee: $__________________
PLEASE ENTER TOTAL REGISTRATION, FOOD AND LODGING, AND EXTENDED STAY OR EARLY ARRIVAL AMOUNT: $_______________
The nearest airports are Atlantic City and Philadelphia International Airports. Round trip ground transportation between the Golden Inn and these airports will be provided on Saturday, October 3, Sunday, October 4, and Wednesday, October 7.
| | Check here if you would like information about making a ground transportation reservation.
| | I have enclosed check or money order payable to CABM Bioinformatics Workshop for the total amount. Purchase orders cannot be accepted. Checks must be payable in U.S. dollars and payable through a U.S. bank.
| | Please charge the Total Amount to my VISA or MasterCard. Sorry, no other cards accepted.
| | VISA No. ____________________________exp. date _____ | | MasterCard No. _______________________exp. date _____
Card Holder Signature ____________________________________
Send this form with payment to: Structure-based Functional Genomics, c/o Ms. Becky Watson, Center for Advanced Biotechnology and Medicine (CABM), Room 019, 679 Hoes Lane, Piscataway, NJ 08854-5638. Ms. Watson can be contacted by telephone at (732) 235-5321, by fax at (732) 235-4850, or by e-mail watson@mbcl.rutgers.edu. You can also find a copy of this application and other information concerning the conference on our web site: http://www.cabm.rutgers.edu/bioinformatics_meeting