Print and Fax to 202-728-9469, Attn: Martrell Kelly
 
"Genetics Policy Forum"


The registration deadline for this conference is Friday, May 17th .

Registration Form - RI

Required fields are indicated with asterisks (*) (if you do not have any information to enter into a required field, just type "NA"). Please check to make sure that your e-mail address is entered correctly. When complete, please fax to (202) 728-9469, Attn: Martrell Kelly; or call Health Systems Research at (202) 828-5100.
Your Contact Information:
First Name*  
Middle Initial  
Last Name*  
Academic Degrees *  
Job Title*  
Department  
Division  
Organization*  
 
Address*  
 
City*  
State*  
Country  
Zip Code*  
Telephone*  
Fax*  
E-Mail*  

If materials are sent out prior to the conference, do you want them sent to a different address?

If so, enter the full address here:

  
Special Needs/Accommodations:  
   
Please order dinner for me on Friday, June 14. I understand that $22 will be deducted from my daily per diem.
Yes
No
 
Please order lunch for me on Saturday, June 15. I understand that $9 will be deducted from my daily per diem.
Yes
No
 
Hotel Reservations:
Yes, please make me a room reservation for the night of Friday, June 14.
Yes, please make me a room reservation for the night of Saturday, June 15.
Yes, please make me a room reservation for both Friday June 14 and Saturday, June 15.
No, I will not need hotel accommodations. I will make my own arrangements.