registration

							                     EICOSANOIDS AND OTHER BIOACTIVE LIPIDS IN CANCER,
                            INFLAMMATION AND RELATED DISEASE
                                                 9TH INTERNATIONAL CONFERENCE
                                                         September 11 - 14, 2005


REGISTRATION FORM

A. PARTICIPANTS (please type)

Family Name:                                                    First Name:

Telephone:                                                      Fax:

Affiliation / Institution:

Street Address:


City:                                                           State/Province:

Country:                                                        Postal Code:

E-mail address:

B. ACCOMPANYING PERSON(S)

Last Name:                                                          First Name:

Last Name:                                                          First Name:

Note: A $150 fee per accompanying person will be charged, which entitles them to the opening reception,
      “Meet the Exhibitors” cocktail gathering and the gala dinner.




REGISTRATION FEES (Check the box which one is applicable)

                                               Before                 After                      Daily
                                               6/15/05                6/15/05
Ph.D./M.D.                                    $495.00                $595.00                    $300.00
Post-Doc Students*                            $345.00                $395.00                    $175.00
Graduate Students*                            $270.00                $325.00                    $100.00
Accompanying Person(s)                        $150.00                $150.00

Conference registration fee also includes opening opening reception, "Meet the Exhibitors" cocktail gathering and the gala dinner.


                                                           (CONTINUED…)
                  EICOSANOIDS AND OTHER BIOACTIVE LIPIDS IN CANCER,
                         INFLAMMATION AND RELATED DISEASE
                                         9TH INTERNATIONAL CONFERENCE
                                               September 11 - 14, 2005


REGISTRATION FORM                     (CONTINUED)


 METHOD OF PAYMENT

1) Check (personal or institutional) should be made payable to:
   THE FUND FOR MEDICAL RESEARCH & EDUCATION


2) Credit Card charges are in the amount of US$

Master Card                    Visa                     American Express

Account Number

Expiration Date                                   Amount

Name of Cardholder


Cardholder Signature



Note:
1. A printed hard copy of the registration form must accompany any check or credit card registration payments.

2. If paying by credit card:

       A. The cardholder’s signature block must be signed by the cardholder.
       B. The cardholder’s credit card statement will reflect a charge from:
           “The Fund for Medical Research & Education”




Mail Completed form to:
Christopher Harris
Wayne State University
Dept. of Radiation Oncology,
431 Chemistry Building
Detroit, MI 48202
(Phone: 313.577.1018)