Public Health in the 21st Century - Conference Reservation Form

Check here for the Conference Registration Form in PDF format (Portable Document Format)
Public Health in the 21st Century:

Behavioral and Social Science Contributions

Atlanta, Georgia May 7-9, 1998
Conference Registration Form

Complete this reservation form and mail with payment to:	American Psychological Association
	Accounting/Public Health's Registration
	750 First Street, NE
	Washington, DC 20002-4242
	or Fax to: (202) 336-5693

Name: ____________________________________________________________
Title:____Dr. ____Mr. ____Mrs. ____Ms

Institution: ______________________________________________________

Discipline: _______________________________________________________

Mailing Address:________________________________________________________________

Work Phone:( )_______________ Home Phone:( )_______________ Fax:( )_______________

E-Mail: _______________________________________

REGISTRATION FEE:
___Before April 1, 1998: $90 ___One-Day Fee: $50 ___After April 1, 1998: $125

FORM OF PAYMENT:
___Visa ___Mastercard ___American Express ___Check
___Purchase Order _______________________________ (Make checks payable to the American Psychological Association. Checks must be drawn on a U.S. bank and U.S. dollars.)

Cardholder name:
(as it appears on credit card) ___________________________________________

Amount to be charged: $________ Credit card number: _______________________________________

Expiration date: _____________ Signature (required): ______________________________________

Hotel reservations must be made directly with the hotel.
For more information, please call: Julia Silva, PhD, conference manager at (202) 336-5817