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Print this page out, fill it out and fax/mail it accordingly. May Las Vegas Registration Form 2nd Annual National Trauma Conference A Special Focus on Cybersex I will attend: O Thursday, May 17, 2001 O Friday, May 18, 2001 O Saturday, May 19, 2001 O All Three Days NAME _________________________________________________________ ORGANIZATION ________________________________________________ ADDRESS ______________________________________________________ CITY ________________________ STATE _____________ ZIP __________ DAYTIME PHONE NO. __________________________________________ A 10% discount is available for groups of 3 or more registering at the same time. A 15% discount is available for full time students (must include documentation of full time status). Only one kind of discount can be applied, discounts can not be combined. Registration postmarked by April 2, 2001: THURSDAY ONLY FRIDAY ONLY SATURDAY ONLY ALL THREE DAYS $60.00 $125.00 $125.00 $299.00 Registration postmarked after April 2, 2001: THURSDAY ONLY FRIDAY ONLY SATURDAY ONLY ALL THREE DAYS $75.00 $150.00 $150.00 $349.00 METHOD OF PAYMENT O Check made payable to FACES O Purchase order enclosed O Charge my O Visa O Mastercard Register by Mail: FACES, c/o Richard Fields, Ph.D. 5010 243rd Ave. NE Redmond, WA 98053

NAME OF CARDHOLDER (Please Print) ___________________________________________ CREDIT CARD NUMBER _______________________________ EXP. DATE _____________ AUTHORIZED SIGNATURE ____________________________________________________ Register by Phone: (877) 63-FACES (425) 868-7253 Register by Fax: (425) 868-5644 ---------------------------------------------------------------------------------------------------- Return to Previous Page