Conference registration form

Use this handy form to register on line for either the Acid-Base Interaction conference or the conference on Silane Adhesion Promoters or The Short Course on Applied Adhesion Measurement Methods or all of these selections. Please fill in the required registration information below.

Name

First name: Last name:
Honorific: Mr. Ms Mrs. Miss Dr.

Address

Title:          
Organization:   
Street address: 
City:            State or Prov:  Postal code: 
Country:        

Phone:           Fax: 
E-mail address:

Notify by: E-mail Fax Mail Phone

Which conference(s) do you want to register for?

Do you require further information on? (Check all that apply.)
Hotel registration
Conference location (maps)
Local transportation
Short course on adhesion measurement techniques
Future conferences

We would appreciate any further comments you may have concerning the conferences?

When you are done

PAYMENT FORM

By submitting this form you automatically secure your name in our registration list. However, before we can confirm your registration we need to receive payment confirmation from you. Note: for security reasons we cannot accept credit card information over the internet at this time. There are, however, several convenient ways to submit your payment:

Call 914-227-7026 (8:00am-5:00pm EST)
Print out payment form below and FAX to: 212-656-1016
Print out payment form below an mail to:

Dr. R. H. Lacombe, Conf. Chair.
C4 Technologies, Inc.
3 Hammer Drive
Hopewell Junction, NY 12533

Cick here to view and print payment form. Fill in and submit as indicated above.

C4 TECHNOLOGIES, INC.
rhlacombe@compuserve.com