REGISTRATION FORM

Deadline -- JUNE 1, 2000

Please fill out a form for each person registering. This form may be duplicated. Your name badge will contain your name, city, state, and major field as printed below on the left:

Name:____________________________________ Mailing Address:_______________________________

City:________________________State:_________ City:_________________State:_________Zip:_______

Major field:________________________________ E-mail:_______________________________________

Telephone: (______)________-___________________

Registration Fees (per person): No refunds after July 1, 2000.

ASA Member $150 $___________

Non-Member $175 $___________

Full-time Student $ 75 $___________

Spouse/Family Member $ 75 $___________

Late fee for registrations

postmarked after June 1 $ 30 $___________ Registration Total $___________

Lodging at Gordon College: Thurs. Fri. Sat. Sun.

Apartments: bedroom, shared bath, and sitting area.

Single occupancy will be $45 per night: $45 X _________ =

Single sleeping - shared bath No. of nights

Double occupancy will be $35 per person per night: $35 X ________ = Double sleeping - shared bath No. of nights

Dormitory style lodging (two - three per room)

$29 per person per night: $29 X ________ = Lodging Total $___________

No. of nights

Meal Package at Gordon College: Friday dinner through Monday lunch: $105

Including a New England Clam Bake on Saturday night.

Please specify ______ Lobster or ______Chicken Meal Total $___________

Whale Watching Trip:

Cost: $25 for adults, $22 for children under 16 years Whale Watching $___________

(Includes admission and transportation)

Pay on board for lunch ($6.00)

TOTAL AMOUNT ENCLOSED $___________

Mail this form with your check made payable in US funds to:

American Scientific Affiliation, PO Box 668, Ipswich, MA 01938

or you may pay via credit card by filling in the information below.

MasterCard or Visa ---

Signature:_______________________________ Expiration date: ____________

Name as it appears on your credit card:________________________________

please print