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PREREGISTRATION FORM

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PREREGISTRATION FORM Powered By Docstoc
					REGISTRATION FORM
                                                                   16th ANNUAL ASN WORLD CONVENTION 2011
                                                                                                                    14-16 APRIL 2011



Name

Affiliation

Preferred Address




City                                                         State

Country                                                      Zip

Telephone                                                    Fax

E-Mail

Occupation

Area of Interest



REGISTRATION FEES
 --ASN Non-Members ......................................................................... 90 $
 --ASN Members ................................................................................ 70 $
 Students .......................................................................................... 50 $

ASN MEMBERSHIP (FOR ALL PANELISTS)
 Regular ........................................................................................... 70 $
 Students .......................................................................................... 40 $

ETHNOPOLITICS (OPTIONAL)
 Please add Ethnopolitics to my ASN membership ......................... 30 $

Total Payment ..............................................................................                  $

METHOD OF PAYMENT
 Check
 Charge :              Visa              MasterCard

                       Name on Card : ...........................................................................

                       Expiration Date : ........................... Card Number : ...................

                       Billing Address : ……………………………………………………….

                       …………………………………………………………………………..



         All panelists must pre-register by March 1st. No refunds are possible after this date.

              This Registration Form can be sent by regular mail, fax or email to the address below:

                           Erin R. Carll, ASN > HARRIMAN INSTITUTE
                 [1215 IAB, Columbia Univ.] 420 W. 118th St., New York, NY 10027
  TEL: 212.854.8487 > FAX: 212.666.3481 erinrcarll@gmail.com > WEB: http://www.nationalities.org

				
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