Read Microsoft Word - 2010 applicant Registration Form text version

Joint Registration Form The 6 International Conference of Neurons and Brain Diseases (ICNBD ­ Aug 3-5, 2011 Toyama, Japan) Membership of the Association for the Study of Neurons and Diseases (AND)

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Mr__Mrs__Ms__Miss__ FirstName: ______________ LastName:__________________ Institution:_______________________________________________________________ Position/Title:____________________________________________________________ Street Address: ___________________________________________________________ City ____________ Province____________ Country____________ Postal ___________ Phone:__________________________ Email:__________________________________ AND Membership: Since AND did not start to offer member benefit till the beginning of 2011. We decide to apply your 2010 fees to the year 2011. By signing your name in the space below. You become AND member starting the date of your signature. Office Use: __ Approve _______________________________ ______________ __ Reject Signature of the Applicant: Date(mm/dd/yy)

Note: If you did not pay for membership in 2010, Please do not use this form. For further information on membership eligibility, responsibilities and benefits, please check the AND website at www.ANDinternational.org. You may also download the correct form from there.

If submitting talk or poster, please check one of following: Talk___ Poster___ Title: _________________________________________________________

Office Use: __ Approve __ Reject

ICNBD Registration Fee: $450 ___ Please read our camp & tour page on www.ANDInternational.org carefully before indicate the number of people interested in each package: kids camp ___ Onsen w/Tour ___ Onsen only ___ Send your registration to The Association for the Study of Neurons and Diseases P.O.Box 1331, Toronto, ON ,Canada, M4P 3J4 Or to a secure fax line at 416.978.7398 Payment Method: ___ check or money order, payable to AND ___ Visa* ___ MasterCard* Name on Card (print please) ____________________ Card No. _____ ______ ______ ______ Expiry Date (mm/yy) ____/____ _________________________________ _______________ Authorized Signature of the Cardholder Date (mm/dd/yy)

*Canadian Dollars are used for all transaction currencies. Application is only completed when application form is completed and payment have been received and processed. You will receive a membership confirmation email upon successful application. For additional information and questions, please refer to www.ANDinternational.org

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Microsoft Word - 2010 applicant Registration Form

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Microsoft Word - 2010 applicant Registration Form