BARCELÓ MAYA BEACH RESORT
Riviera Maya, Q. Roo, Mexico
December 7-10, 2011
REGISTRATION EXTENDED TO SEPTEMBER 15, 2011
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
| REGISTRATION FORM |
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Prof. ¨ Dr. ¨ Mr. ¨ Ms. ¨ Mrs. ¨ Miss ¨
Name Organization Mailing Address City State Zip Country Phone Fax
¨ $450 Member Registration ¨ $500 Non-Member Registration ¨ $150 Member Student Registration ¨ $175 Non-Member Student Registration
¨ $100 Accompanying Guest Name:
¨ $50 Discount early registration (before SEPTEMBER 15, 2011)
Total Amount Due: $
Payment by: ¨ Check ¨ Credit Card
¨VISA ¨MASTER CARD ¨AMEX
Exp. Date
Account # Signature
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