2004 1st Conference on Advanced Nanotechnology
Registration Form

PLEASE PRINT
and fax or mail this form to:
Foresight Institute, Box 61058
Palo Alto CA 94306 USA
Tel: 650-917-1122 · Fax: 650-917-1123

Name: ________________________________________
Address: ________________________________________
 ________________________________________
City, State: ________________________________________
Zip/Postal Code, Country: _________________________________
Phone: ________________________________________
Fax: ________________________________________
Email: ________________________________________
Position (professor, director, programmer, etc.):
 ________________________________________
Organizational affiliation (for your badge):
 ________________________________________
How did you hear about this conference:
· email · web · publication: 
· other: 
 ________________________________________
Please make checks payable to the Foresight Institute.
Checks and bank drafts must be in U.S. dollars drawn on a U.S. Bank.
VISA or MasterCard Number: _______________________________
Exp. Date (Month/Year): ____________________________
Signature: ________________________________________
Print name as it appears on credit card:
________________________________________

 ___ Yes, include my contact information: name, badge affiliation,
and email on an attendee list.
 ___ No, do not include my contact information on an attendee list.
Friday-Sunday 0ct. 22-24, 2004   after Aug. 31

Conference with LUNCH (Oct. 22-24)
Three day (Fri, Sat, Sun)   $595
Two day (Fri, Sat · Fri, Sun · Sat, Sun)***   $415
One day (Fri · Sat · Sun)***   $230
Full-time Student (Fri, Sat, Sun)**   $230

Conference with NO LUNCHES* (Oct. 22-24)
Three day (Fri, Sat, Sun)   $495
Two day (Fri, Sat · Fri, Sun · Sat, Sun)***   $335
One day (Fri · Sat · Sun)***   $190
Full-time Student (Fri, Sat, Sun)**   $135

Discount code: __________________

Optional Item:
Prize Banquet (Fri, Oct. 22)   $80

*** For two day and one day registrations, please circle the desired days.
** Full-time students must fax a copy of a current university student ID with the registration form.
* No lunch option omits lunch on Friday, Saturday and Sunday.
Conference:   $ _____
Prize Banquet:   $ _____
TOTAL:   $ _____

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Last updated 26 June 2004. The URL of this document is: http://www.foresight.org/Conferences/AdvNano2004/RegForm.html