Registration
2005 Becklinfest Conference

Title: _____Prof. _____Dr. _____Mr. _____Mrs. _____Ms.

Last Name: _________________________________________________ Middle Initial _____

First Name: _________________________________________________

Affiliation/Institution: _____________________________________________________

Address: ________________________________________________________________

________________________________________________________________________

City: ______________________ State/Province: _______________ Postal/Zip Code ____________

Country: ____________________________ Phone Number: ____________________________

Fax Number: _________________________ E-mail: ___________________________________

Number of additional guests you will bring: ______

Guest name(s): 1.___________________ 2. ______________________3. ____________________

Conference Registration (including one Friday night Banquet ticket) _____ $100

Conference Registration (without a Friday night Banquet ticket) _____ $75

I would like to purchase: _____1 ($25) additional Friday night Banquet tickets (guest tickets are $25/person-there will be no refunds)

Please reserve the following meal for me     _______chicken       ________steak           _________vegetarian

(fax must be received by March 18th or envelope must be postmarked by March 18th):

Make Check Payable to "UC Regents" OR

Complete the following credit card information:

Credit card type: _____VISA; _____Mastercard: _____Discover Card;

Cardholder name: ______________________________________________

Card number: _________________________________ Expiration Date: _________________

Billing Address zip code: ___________________

Card Holder's Signature: ______________________________________

Fax to : Becklinfest Coordinator (310) 267-0272  OR
Mail to: Becklinfest, UCLA, Dept. of Phys. & Astro., 430 Portola Plaza Rm 3-437, Los Angeles, CA 90095-1547