Name ______________________________________________________________

Address ___________________________________________________________

City_________________________________State________Zip______________

Telephone____________________________E-mail________________________

Payment method: Check___Visa___MC___

Card #____________________________Exp. Date_____
 
Pre-registration       (By 9/26)       On-site registration
 
CPSR                    $65 _______       $75 _______

Non member              $90 _______      $100 _______

New CPSR membership ($50 value)
   & registration       $95 _______      $105 _______
 
Low income/student      $30 _______       $35 _______
 
Wiener Award Ceremony    $5 _______        $5 _______

Attend Ceremony without registration      $30 _______
 
Additional donation to further CPSR's work  $ _______
 
Total enclosed:                             $ _______

A limited number of scholarships are available.

Send with check or credit card number to:

CPSR
P.O. Box 717
Palo Alto, CA 94302
 cpsr @ cpsr.org 

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