Registration Form

Family Name: First Name
Affiliation:
Address:
Address:
City/Town: State/Province:
Postal Code: Country:
Telephone: Fax:
E-mail:

Registration Fee

Affiliation	If payment received on or before 28 February 2004	If payment received after 28 February 2004
Company/Industry	$500	$550
Academic Faculty/Staff	$300	$330
Government/Hospital	$300	$330
Postdoctoral Fellows and Full-time students (letter from superviser required)	$150	$165

A: Registration Fee (not including conference dinner)		=
B: Conference dinner sold out
Overall Total Payment:	A + B	=

Payment Methods (All registrations must be received before Thursday, May 6, 2004.  There will be no on-site registration at the conference.)

I am paying by check. Checks must be made out in US Dollars and drawn on a US bank. Make checks payable to "Boston Chapter ASA". Mail the check and a copy of the completed registration form to
BCASA, P.O.Box 67473, Chestnut Hill, MA 02467 USA

I have transferred the total amount of US$________ to the following bank account.
Bank Name: University Credit Union                                            Routing #: 211080767
Account Owner's Name: Boston Chapter of the A.S.A.             Account Number: 254006
Bank Address:  846 Commonwealth Ave, Boston, MA  02215 USA
Please note that the bank transfer fee (where applicable) must be paid by the participant. Please attach a copy of the bank transfer receipt to the completed registration form to  
BCASA, P.O.Box 67473, Chestnut Hill, MA 02467 USA

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Click here for a downloadable version this registration form in pdf file.