Please abbreviate long names and affiliations the way you would prefer to see them on your badge.
NAME: ________________________________________________________________________
AFFILIATION: _________________________________________________________________
ADDRESS: _____________________________________________________________________
_______________________________________________________________________________
PHONE: _________________ FAX: _________________ E-MAIL: ______________________
If payment covers more than one person, please list their badging information.
Badge Name: ________________________________ Affiliation: _____________________________
Badge Name: ________________________________ Affiliation: _____________________________
____ @ $50 | Professional Registration through February 22 | $_________ |
____ @ $70 | Professional Registration starting February 23 | $_________ |
____ @ $30 | Student Registration through February 22 | $_________ |
____ @ $50 | Student Registration starting Febraury 23 | $_________ |
____ @ $0 | 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 22, 1999, to 30th 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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