pagregfax

Fax Registration Form

Complete this form online then print and fax to 201-653-5705.

Scherago International, 525 Washington Blvd, Ste 3310, Jersey City, NJ 07310

For university, non-profit and Government participants the fee will be:
$565 advance registration, postmarked/faxed by 15 October 2010 / $665 after 15 October / $765 On-site in San Diego

For industry participants the fee will be:
$790 advance registration, postmarked/faxed by 15 October 2010 / $890 after 15 October / $990 On-site in San Diego

For students (Pre-Ph.D - Requires a letter of certification from your dept. chairperson) the subsidized fee will be:
$375 advance registration, postmarked/faxed by 15 October 2010 / $425 after 15 October/ $475 On-site in San Diego

For the weekand rate - Univ/Non-Profit/Government (Fri, Sat & Sun only), the subsidized fee will be:
$415 advance registration, postmarked/faxed by 15 October 2010 / $465 after 15 October 2010 / $515 On-site in San Diego

For the weekand rate - Industry (Fri, Sat & Sun only), the subsidized fee will be:
$515 advance registration, postmarked/faxed by 15 October 2010 / $565 after 15 October 2010 / $615 On-site in San Diego

Have you ever attended a PAG conference (Circle one): Yes ------- No

Full Name (e.g. Mr. Darrin Scherago):
Company / University / Affiliation:
Address:
City, State:
Postal / Zip Code:
Country:
Telephone Number: (Include Country Code):
Fax Number: (Include Country Code)
E-mail Address:
Credit Card: (VISA / MC) No American Express or Discover
Credit Card Type: (Debit / Credit)
Credit Card Number: (1234-5678-9012-3456)
Credit Card ID#:
Credit Card Billing Zip Code:
Expiration Date: (MM/YY) Must be Current.
Amount:
Main Interest: (Plant / Animal)