ICSTR

ICSTR Registration Form

Title	Mr Mrs Prof Dr
First name:
Middle initial:
Last name:
Organization:
Address (line 1):
Address (line 2):
City:
State:
Zip code:
Country:
E-mail address:
Phone number:
Fax number:

Password:
Confirm password:

Fees

Please check if you are interested in

Conference excursion to New York City

Accompanying persons’ programs

Additional banquet tickets ($50.00 ea.)

Registration Fee

Active Participant $500.00 US ($600.00 after May 15, 2002)

Student* $350.00 US ($350.00 before or after May 15, 2002)

Registration Type:

*Student Declaration: If you are a full-time graduate student, please give the name of your supervisor and their e-mail address so that we may verify your student status

Supervisor's name:

Organization:

Supervisor's e-mail:

IMPORTANT

Unfortunately, due to security related issues, we are unable to process credit card information online.

We are only processing credit card orders via phone and fax.

To complete registration and process your payment, please contact us by phone or fax with the following information:
- Your full name
- Your ICSTR registration username
- Your credit card information (Cardholder's name, Card Type, Expiration Date)

Rutgers ICSTR Registration
Attn:  Phyllis Cassell

Fax (732) 445-6264
Phone (732)445-5036

You will only be charged for the amount disclosed in the box below.

Payment(Credit Card or International Check in US dollars)

$ Total amount

Payment Type

Cancellation Policy: Cancellation without penalty can be made before June 1, 2002. Cancellation made prior to

July 1^st will incur a penalty of 20% of the registration fee. No refund will be given for cancellation
after July 1^st.

Registration Fee
	Active Participant	$500.00 US ($600.00 after May 15, 2002)
	Student*	$350.00 US ($350.00 before or after May 15, 2002)
	Registration Type: