Parkinson’s Disease, Environment and Genes
August 25 - 28, 2001 l Doubletree Hotel World Arena l Colorado Springs, Colorado

Registration Form

Name/Degrees/Title____________________________________________________________________________

Organization/Institution__________________________________________________________________________

Address______________________________________________________________________________________

City State ZIP Country_________________________________________________________________________

Phone (_____ )______________________________ Fax (_____ )_____________________________________

E-mail _____________________________________________________________

Please Pre-register!!! Tel: (501) 661-7962 • Fax (501) 661-7968

Registration Fee (Includes Admission to All Sessions, Conference Packet, Program, Abstract Book, Speaker Biographies, Pre-Registrant’s Address Listing, Welcoming Reception, Conference Social Evening and Dinner, Refreshments during Breaks, Snacks during Poster Session, and Peer Reviewed Conference Papers published in a special Issue of NeuroToxicology.)

		Advanced Registration Rec’d by June 1, 2001	Pre-Registration Rec’d by July 1, 2001	On-Site or Rec’d After August 1, 2001	Number	Total
	Registration Fee	$395	$495	$595
	Academia/ Government/NPO’s	$200	$250	$325
	One-Day Registration	$125	$150	$175
	Student (Student ID required)	$50	$75	$95
	Press / Media (Press ID required)	$0	$0	$0
	Banquet Ticket for Non-Registered Guest	$40	$40	$40
				TOTAL ENCLOSED	$

Special Assistance Needed. All conference facilities comply with ADA requirements. If you require Special Assistance, please contact the Conference Administrator.

Cancellation / Refund Policy: Refunds will be made for cancellations received in writing by August 1, 2001. A handling fee of $50.00 is deducted for cancellation. No Refunds after August 1, 2001.

Method of Payment:
Check payable to "UAMS NEUROTOXICOLOGY CONFERENCE" (US Dollars Only)
Purchase Order Enclosed.
Payment by Credit Card: VISA or Mastercard Only. (Fill in Below)

Number_______________________________________ Exp. Date________________________________

Name on Card:__________________________________ Signature:_______________________________

Phone, Fax, or Mail Registrations to:
NEUROTOXICOLOGY CONFERENCE
UAMS Continuing Medical Education
4301 West Markham, Slot 525-1 • Little Rock, AR 72205 USA
Tel: (501) 661-7962 • Fax (501) 661-7968