REGISTRATION FORM REGISTRATION FORMThe Grace Hopper Celebration of Women in Computing
MAIL: Send registration form with check or credit information to:
FAX: Send registration form with credit card information to:
PHONE: Please have credit card information at hand and call:
Name:_______________________________________________
Title:______________________________________________
Affiliation:________________________________________
Mailing Address: ______________________________________________________
City/State:____________________________________________________________
Country:_____________________________ Zip Code________________
Telephone:________________
Fax:______________________
Email:____________________
Payment:
Please mark payment method: ___Visa ___Mastercard
___Check (payable to George Washington
University)
Check category:
___ $350 Regular Registration
___ $150 Student Registration - Student I.D.#_________________ School_______________________________
Amount Enclosed _______________________
Credit Card Number ____________________
Card Expiration Date __________________
Name on card (print or type) ______________________________
Signature _________________________________________________