Registration Form

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					August 8-11, 2005 San Jose Convention Center San Jose, CA

Registration Form
Choose your Conference Package:
(All Conference packages include admission to the expo hall) Platinum Passport (August 8-11, 2005) One Day Conference Specify One Day: $595 Monday Tuesday $695 Wednesday Thursday Through July 26 $1695 After July 26 $1795 Expo Hall Registration Free in advance- $25 On-Site To register in advance you must register at

Please fill out form completely and mail or fax with payment to the address below.

First Name: ______________________________________________

Card Holder’s Name: Credit Card Type: Credit Card Number: ______________________________________ ________________________________________ ______________________________________

Last Name: _______________________________________________ Corporate Title: Company Name: Street Address: ___________________________________________ __________________________________________ ___________________________________________

Month/Year card expires: ___________________________________ Other: _________________________________________________

City: _____________________________________________________ State or Prov.: Zip/Postal Code: ____________________________________________ __________________________________________

NOTE: REGISTRATION FORM AND PAYMENT MUST BE RECEIVED TOGETHER TO BE PROCESSED. Cancellations and Substitutions If you must cancel for any reason, notify our registration department in writing by fax (203) 286-1010 or email by July 8, 2005. Your registration will be refunded less a $100.00 processing fee. Cancellations after July 8, 2005 are non-refundable. You may transfer your registration to another person at any time by providing written authorization. How did you hear about us?: ______________________________

Country: _________________________________________________ E-mail Address: __________________________________________

*Providing your e-mail address to us indicates that you may be interested in receiving future e-mail promotions about other Jupitermedia events.

Check to opt-out Telephone: _______________________________________________ Fax: _____________________________________________________ Please Note: Jupitermedia Corporation reserves the right to make changes to the events program. Unforeseen circumstances may result in the substitution of a presentation, topic or speaker. You consent to Jupitermedia Corporation recording and/or photographing the event and using such items, including your likeness, in future promotions. Jupitermedia Corporation reserves the right to reject or rescind any registration and return any fees accordingly. Registrant assumes all risks incidental to participation in all event activities, including loss or damage to property. Jupitermedia Corporation's total liability shall be limited to the amount of fees received, if any, from a particular registrant.

__________________________________________________________ __________________________________________________________ If other: __________________________________________________ __________________________________________________________ __________________________________________________________

Priority Code:


Registration Department Phone: (203)662-2857 Fax: (203)286-1010

Mail your completed registration form with payment to (checks payable to Jupitermedia Corporation): Jupitermedia Corp, Attn: CFO, 23 Old Kings Highway South, Darien, CT. 06820

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Description: Registration Form