FAS 2010 CONFERENCE REGISTRATION FORM
One form MUST BE COMPLETED for EACH person registering.
Be sure to print a copy of each form for your records.

Name:
Employer:
Address:
City:
State:
Zip:
Phone:
E-Mail:

REGISTRATION FEES
(Please check appropriate category.)

 Early Registration  (closed)                                                    Regular Registration
(submitted or postmarked before 1 Feb 2010)         (submitted or postmarked after 31 Jan 2010)

 

 Member  $45.00
Student Member  $20.00
Non-Member  $60.00
Student Non-Member  $30.00
 

MEMBERSHIP DUES
(If you are joining or have not yet paid 2010 dues, please check membership category.)

Regular $30.00
Student $15.00
Sustaining $40.00
Life $500.00 		Patron $1000.00
Corporate $200.00
Institutional $100.00

ANNUAL BANQUET
The annual banquet will be held on Friday, 19 March 2010.
Time: 7 PM
Location: Treasure Coast Public Safety Training Complex at IRSC
Menu: Choice of chicken or fish

Pre-registration for the banquet is required.

The cost of the banquet is $24.00

Check Money Order MasterCard
Visa American Express  
Card Number: Exp. Date: /
Cardholder's Name:
Your Zip Code:

Registration Fee
Membership Dues (if applicable)
Banquet Tickets ($24.00 each)
Payment Total Amount


 Or
Print and Mail completed form to:
Florida Academy of Sciences
Orlando Science Center
777 East Princeton Street
Orlando, FL 32803
Copyright © 2009 Florida Academy of Sciences All Rights Reserved.