Hilton Sonoma Wine Country
Santa Rosa, California USA
REGISTRATION
To register send the completed registration form
below (copy below and email to
lesiar@vt.edu) with
remittance to Lesia Linkous, Division of Polymer Chemistry, Inc., Virginia
Tech, 410 Davidson Hall, M.C. 0279, Blacksburg, VA 24061. Phone:
540-392-3042, Fax: 540-231-2588, E-mail:
lesiar@vt.edu
Prof. Dr. Mr. Ms. Mrs. Miss
Name
Organization
Mailing Address
City State Zip
Country
Phone Fax
E-mail
__ $725 Member Registration
__ $775 Non-Member Registration
__ $250 Member Student Registration
__ $300 Non-Member Student Registration
__ $50 Late Fee (after August 1, 2011)
Total Amount Due: $
Payment by: __ Check __ Credit Card
__VISA __MASTER CARD __AMEX
Exp. Date
Account #
Signature
Name
Organization
Mailing Address
City State Zip
Country
Phone Fax
__ $725 Member Registration
__ $775 Non-Member Registration
__ $250 Member Student Registration
__ $300 Non-Member Student Registration
__ $50 Late Fee (after August 1, 2011)
Total Amount Due: $
Payment by: __ Check __ Credit Card
__VISA __MASTER CARD __AMEX
Exp. Date
Account #
Signature
Please make checks payable to "ACS Division of Polymer Chemistry Inc." mail to attn: Lesia Linkous, POLY Conference Planner, 410 Davidson Hall MC 0279, VA Tech, Blacksburg, VA 24061 USA.
