MOdeling DEnse STellar system conference (MODEST-6) | August 29-31, 2005 | Northwestern University

MODEST-6 LUNCH/PARKING PAYMENT FORM

___ I would like to purchase the 3-day lunch package for US$ 20.00 and I will pay by:

      ___ credit card (information below) ← STRONGLY PREFERRED

      ___ cash or check at registration

___ I also need parking permits for ___ days at $6/day


Email address: ________________________________________
(Please PRINT)

Credit card payment information:

Full Name as on card: __________________________________
(Please PRINT)

Card type: ____________________________________________

Card number: _________________________________________

Expiration date: _______________________________________

I authorize you to charge US$ 20.00 to my card, plus $6 per parking permit.



Signature: ____________________________________________

RETURN THIS BY AUG 19 TO MARSHA COFFEY:
by email (at your own risk!) to m-coffey@northwestern.edu OR by FAX to +1 847 491 9982