PAY BY CHECK REGISTRATION FORM – REGULAR

FAS 2017 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
.

If you would like to pay using a credit card please click here

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

REGISTRATION FEES
(Please check appropriate category.)

Regular Registration
(submitted or postmarked after 31 Jan 2017)
FAS 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 2017 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, 10 March 2017. IST Commons, Florida Polytechnic University
Time: 7:30 PM
The banquet will be buffet-style.

The banquet speaker will be Dr. George Maul (the 2016 FAS Medalist) from
the Florida Institute of Technology
Pre-registration for the banquet is required.
The cost of the banquet is $35.00

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 ($35.00 each)
Payment Total Amount


Print and Mail completed form to:
Florida Academy of Sciences
P.O. Box 149766
Orlando, FL 32814-9766