NAME: _________________________________________________________________
AFFILIATION: __________________________________________________________
ADDRESS: ______________________________________________________________
________________________________________________________________________
PHONE: __________________________ FAX: _________________________________
E-MAIL: ________________________________________________________________
____ @ $50.00 | Professional Registration through February 18 | $_________ |
____ @ $70.00 | Professional Registration starting February 19 | $_________ |
____ @ $30.00 | Student Registration through February 18 | $_________ |
____ @ $50.00 | Student Registration starting Febraury 19 | $_________ |
____ @ $00.00 | Working Press | $_________ |
Total Enclosed | $_________ |
Please Indicate Method of Payment |
---|
O | Check or money order payable to the Lunar and Planetary Institute (checks must be in U.S. dollars drawn on a U.S. bank). |
O | AmEx | O | VISA | O | MasterCard |
Card Number _______________________________________ Expiration Date ____________________
Name as It Appears on Card (PLEASE PRINT) ______________________________________________
Signature ____________________________ Authorization Code (LPI USE ONLY) ________________
RETURN THIS FORM BY FEBRUARY 18, 2000, to 31st LPSC Registration, Lunar and Planetary Institute, Publications and Program Services Department, 3600 Bay Area Boulevard, Houston TX 77058-1113. For registration information contact the LPI Publications and Program Services Department (phone: 281-486-2142; fax: 281-486-2125; e-mail: tanner@lpi.usra.edu).
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