February 20 - 23, 2011
Asilomar Conference Grounds
Pacific Grove, California USA

REGISTRATION

 To register, complete and submit the below registration form
or
forward a hard-copy registration form (click here) to Lesia Linkous, Division of Polymer Chemistry, Inc., Virginia Tech, 410 Davidson Hall, M.C. 0279, Blacksburg, VA 24061.  Phone:  540-231-3029, Fax:  540-231-2588, E-mail:  lesiar@vt.edu.

Registration Form
First Name
Last Name
Company
Address
City
State
Zip code
Country
Phone
Fax
Email
Registration Type
$625 POLY Member Registration
$675 Non-Member Registration
$125 POLY Member Student Registration
$175 Non-Member Student Registration
$125 Accompanying Guest
Guest Name:
$50 Late Fee (after January 6, 2011)

Total Amount Due
 		Comments

Payment Information
Credit Card   Check    Please invoice


Credit Card Type


Name as it appears on the credit card
Expiration Date
Card Number
Signature (type your name)




this form is powered and secured by Formail.asp, "Sorted Sites"

Please make checks payable to "ACS Division of Polymer Chemistry Inc." mail to attn:  Lesia Linkous, POLY Conference Planner, 410 Davidson Hall MC 0279, VA Tech, Blacksburg, VA 24061 USA.