ISAM Focus Symposium and Workshop: Mucociliary/Cough Clearance as a Biomarker for Therapeutic Development

October 21-22, 2008, Sheraton Imperial Hotel and Convention Center, Research Triangle Park, NC

Payment must accompany registration. Print out this form and mail or fax. Please print or type.

Name_____________________________________________________________________________

Mailing Address_____________________________________________________________________

City_________________________________________________State_______Zip________________

Daytime Phone (______)______________________________________________________________

E-mail (please print clearly) ____________________________________________________________

UNC-Chapel Hill uses the Personal ID number (PID) to aid in keeping records for students and participants. If you already have a PID, please enter it.

PID #______________________________________________________________________________

Are you an alumnus of UNC-Chapel Hill? __Yes __No. If yes, when did you graduate?________________

If you do not already have a UNC PID, one will be assigned to you. Please provide the following information required for PID number creation:

Gender: M   F      Birth Date_________________________________________________________

disability symbolPlease indicate the accommodations and/or services you require to participate: _________________________________________________________________________________

Registration Fee  

Academic, Non-profit, or Government ISAM member: $225 before August 15, $325 after August 15.

Academic, Non-profit, or Government non-ISAM member: $300 before August 15, $400 after August 15.

For-profit Industry ISAM member: $450 before August 15, $550 after August 15.

For-profit Industry non-ISAM member: $600 before August 15, $700 after August 15.

For our information, please check applicable box(es) below:

I plan to attend the dinner (included in your registration fee) at the NC Museum of Art.

I will bring a dinner guest (a non-registered person) for an additional fee of $70 (payment must accompany this registration).

I request a vegetarian meal.

I will not attend the dinner.

I plan to participate in the tour of UNC laboratories on the afternoon of October 22.

Payment must accompany registration. Method of payment:

Check for $________ enclosed, payable to the Friday Center (Federal ID#56-6001393).

VISA or MasterCard (Credit card registration may be received by mail, fax, or phone.)

Expiration date___________________________________________________________________

Card #_________________________________________________________________________

Cardholder's signature_____________________________________________________________

Third-party payment

Name of third party ________________________________________________________________

Contact person/organization _________________________________________________________

Purchase order # __________________________________________________________________

Mailing Address___________________________________________________________________

City_________________________________________________State_______Zip______________

 

Mail or fax this form with payment to:
ISAM Focus Symposium and Workshop
CB 1020, The Friday Center
UNC-Chapel Hill
Chapel Hill, NC 27599-1020
Fax: 919-962-5549
Phone: 800-845-8640 or 919-962-2643