Pre-registration form (PDF format) - Paleopathology Association

BOTH PAGES OF THIS FORM MUST BE SUBMITTED FOR REGISTRATIONTO BE COMPLETEBOTH PAGES OF THIS FORM MUST BE SUBMITTED FOR REGISTRATION TOBE COMPLETEPaleopathology Association39th Annual Meeting (North America)April 10-11, 2012, Portland, OregonPre-Registration Form: PAYMENT INFORMATIONPre-registration deadline is February 27, 2012 (postmarked). After this date the registration fees increase. Non-United Statesmembers can pay on site but must send in the pre-registration form by the deadline to qualify for the pre-registration rate.Name of person pre-registering _______________________________________Pre-registration PaymentPayment options:o Checks (US dollars only) payable to The Paleopathology Association.o Cash (for Non-US members ONLY—cash can be paid on-site)o Credit card (VISA or MasterCard). We cannot accept wire transfers.______________________________________________________________________________________________Fees:Total preregistration fee$______________TOTAL PAYMENT $_____________________________________________________________________________________________________________________________I am enclosing a check or money order in U.S. dollars_____ I am traveling internationally and will pay with cash on-site_____I am paying by credit card: VISA_____ MasterCard_____FOR CREDIT CARD PAYMENTS:Name as it appears on credit card _________________________________________Credit card number _________________________________________ Expiration Date ___________Total Amount to be charged to credit card $___________Please return BOTH PAGES OF THIS form to:Marie Danforth ATTN: PPADept of Anthropology and SociologyUniversity of Southern Mississippi118 College Dr #5074Hattiesburg, MS 39406treasurer@paleopathology.org