Institute for Advanced Neurosciences 2nd Annual Meeting of the Minds
Date: 05/30/2012
Affiliation/Organization/Institution (As you would like it to appear on your name tag):
Prefix
First Name (As you would like it to appear on your name tag):
Last Name (As you would like it to appear on your name tag):
Suffix
Title
Primary Phone:
Email (
COMPLETE
Internet Email Address
jdoe@someplace.com
):
Verify Email:
Mailing Address
(Should match your billing address on your credit card statement)
:
Street Address:
Address cont.:
Address cont.:
City:
State:
Postal/Zip Code:
Country:
Work Address
Street Address:
Address cont.:
Address cont.:
City:
State:
Postal/Zip Code:
Country:
Institute for Advanced Neurosciences 2nd Annual Meeting of the Minds
Select your Attendee type: (Valid Student Photo ID is required at the door for Students)
Stony Brook Faculty or Staff
Licensed Health Care Professional
Student
Guest Speaker
General Public
Fee: (Students & Guest Speakers are free. All other attendees pay $25)
Form Developed by Last Modified 05/30/2012 01:59:13 AM