NAME: ________________________________________________________________________
AFFILIATION: _________________________________________________________________
ADDRESS: _____________________________________________________________________
_______________________________________________________________________________
PHONE: _________________ FAX: _________________ E-MAIL: ______________________
____ × $50 | Professional Registration through 8/21/98 | $_________ |
____ × $70 | Professional Registration starting 8/22/98 | $_________ |
____ × $30 | Student Registration through 8/21/98 | $_________ |
____ × $50 | Student Registration starting 8/22/98 | $_________ |
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 August 21, 1998, TO Moon98 Workshop 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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