Structural Genomics and the Pharmaceutical Industry Registration Form

To register, complete this form and send with payment by November 5, 1999. Registration is limited to 150 participants. Registration forms will be accepted only by mail or fax.

Please type or print:
____________________________________
Name

____________________________________
Company/Institution

____________________________________

____________________________________
Address

____________________________________
City, State, Zip, Country 		(_____)_______________________ Phone (including area code)

(_____)_______________________ Fax (including area code)

______________________________ e-mail
The nearest airports are Newark International Airport and Philadelphia International Airport. Ground transport information can be found on the home page.

Registration Fee $100.00
If paying by credit card:

|   | Please charge the total Registration fee to my
   VISA or MasterCard. Sorry, no other cards accepted.

|   | VISA No. ______________________ exp. date _____

|   | MasterCard No. _________________ exp. date _____


Card Holder Signature ____________________________

If paying by check:

|   | I have enclosed a check or money order payable to CABM Bioinformatics Workshop for the total amount.

Checks must be payable in U.S. dollars and payable through U.S. bank.

Purchase orders CANNOT be accepted.

Send this form with payment to: Structural Genomics, c/o Ms. Becky Klein, Center for Advanced Biotechnology and Medicine (CABM), Room 019, 679 Hoes Lane, Piscataway, NJ 08854-5638.

For more information, call (732) 235-5321, fax inquiry to (732) 235-4850, or send us an e-mail klein@cabm.rutgers.edu. A registration form, hotel information, and ground transportation information are available at our web site www-nmr.cabm.rutgers.edu/workshop99/