SEVENTEENTH INTERNATIONAL NEUROTOXICOLOGY CONFERENCE

SEVENTEENTH INTERNATIONAL NEUROTOXICOLOGY CONFERENCE

Children’s Health and the Environment

Mechanisms and Consequences of Developmental Neurotoxicology

October 17-20, 1999 · DoubleTree Hotel · Little Rock, Arkansas USA

Registration Form

Name/Degrees/Title ____________________________________________________

Name as it should appear on badge ______________________________________________________________

Organization/Institution _______________________________________

Address _________________________________________________________

City_____________________ State_______ Zip _________ Country ______________________

Phone ( ) __________________________________ Fax ( ) ______________________

E-mail: ___________________________________________________________________

Please Pre-register!!!
Tel: (501) 320-3604
Fax (501) 320-4978
Registration FEE (Includes Admission to All Sessions, Conference Packet, Program, Abstract Book, Speaker Biographies, Pre-Registrant’s Address Listing, Continental Breakfasts, Welcoming Reception, Conference Social Evening and Dinner, Refreshments during Breaks, Snack during Poster Session, and Conference Papers published in a special Issue of NeuroToxicology.)

	Advanced Registration Rec’d by Aug. 30, 1999	Pre-Registration Rec’d by Sept 30, 1999	On-Site or Received After Sept 30, 1999
				Number	Total
q Registration Fee	$395	$495	$595	________	________
q Academia/Government	$200	$250	$325	________	________
q One-Day Registration	$125	$150	$175	________	________
q Student (ID Required)	$50	$75	$95	________	________
q Press / Media	$0	$0	$0	________	________
q Banquet Ticket for Non-Registered Guest	$	$	$40	________	________
			TOTAL ENCLOSED
$________	________

Cancellation / Refund Policy:
Refunds will be made for cancellations received in writing by September 30, 1999. A handling fee of $50.00 is deducted for cancellation. No Refunds after September 30, 1999.

Method of Payment:

q Check payable to "UAMS Neurotoxicology Conference" (US Dollars Only)

q Purchase Order Enclosed.

Payment by Credit Card: q VISA or q Mastercard Only. (Fill in Below)

Number _________________________________________________________
Expiration Date: _________________________________

Name on Card: _________________________________
Signature: _________________________________ X

Phone, FAX, Mail or E-Mail Registrations to:

Neurotoxicology Conference

UAMS / Dept of Pediatrics

ATTN: Tina Daniel, Conference Coordinator

1120 Marshall Street ~ Room 304

Little Rock, AR 72202 USA

DanielTinaM@exchange.uams.edu

Phone: 501-320-3604

FAX: 501-320-4978