FLORIDA ACADEMY OF SCIENCES

FAS 2012 CONFERENCE REGISTRATION FORM
One form MUST BE COMPLETED for EACH person registering.
Be sure to print a copy of each form for your records.
This form is to be used when sending registration by mail. A separate form is available for electronic registration.

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

REGISTRATION FEES
(Please check appropriate category.)

Early Registration is Closed Regular Registration
(submitted or postmarked before 1 Feb 2012) (submitted or postmarked after 31 Jan 2012)

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

MEMBERSHIP DUES
(If you are joining or have not yet paid 2012 dues, please check membership category.)

Regular $35.00
Student $20.00
Sustaining $45.00
Life $500.00

Patron $1000.00
Corporate $200.00
Institutional $100.00

ANNUAL BANQUET
The annual banquet will be held on Friday, 16 March 2012.
Time: 7:30 PM
The banquet will be buffet-style.
The banquet speaker will be Dr. Michael Greenberg (the 2011 FAS Medalist) from the Whitney Marine Laboratory.

Pre-registration for the banquet is required.

The cost of the banquet is $25.00

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 ($25.00 each)
Payment Total Amount