REGISTRATION FORM - Please Print this form
2ND INTERNATIONAL CONFERENCE CANCER ON THE INTERNET
Please complete this form  by August 27, 2004
American-Italian Cancer Foundation
112 East 71st  Street
Suite 2B
New York, NY 10021		 FAX to 212-517-6089

For more information, please call Jill Vertes at 212.628.9090.

   
PARTICIPANT'S DETAILS:
Last Name ___________________________ First Name __________________________
Street __________________________________________________________________
City  ____________________  Zip or Postal Code ____________ Country _______________
Telephone number _______________________ Fax number _________________________
e-mail address _____________________________________________________________
 
REGISTRATION: In Person Attendance

Early registration by August 13
Late registration by August 27
Non-profit organizations USD 150 EUR 125 USD 200 EUR 170
Individuals USD 200 EUR 170 USD 250 EUR 210
Club ESO Members USD 180 EUR 150 USD 225 EUR 190
Individuals from countries with limited resources USD 150 EUR 125 USD 200 EUR 170
 
REGISTRATION: On Line Conference
Minimum PC requirements: Broadband  Access, Windows 95 or newer OS, 64MB or more of RAM.             
    Special offer: All online registrants will receive a CD copy of all general session presentations.
by August 27
Individuals USD 100 EUR 85
Club ESO Members USD 90 EUR 75
Individuals from countries with limited resources USD 25 EUR 20
     
PAYMENT DETAILS:    
  Credit cards will be billed by ESO:
If registering by MAIL (US Postal Service), please send PERSONAL OR BUSINESS CHECK  with this REGISTRATION FORM to the address above. PLEASE MAKE CHECKS OUT TO 'AICF'.

If registering by FAX  please use CREDIT CARD, by filling in your information directly to the right. -------->

 
Visa card MasterCard American Express
Card Holder's Name _________________________
Card No. _______ - _______  -  ______  -  _______
Exp. Date ____ / ____
Signature _________________________________
Date ____ / ____