Name:
Affiliation:
Mailing Address:
Phone:
Fax:
Email:
Registration Options:	Option 1 Option 2 Option 3 Option 4 Option 5 Option 6
Additional Options:
Option 1
Option 2
Option 3
Option 4
Option 5
Option 6
Form of Payment
Credit Card Number
Expiration
OR
I will forward my check payable to Plaza Meetings at 3 School Street, Latham NY 12110
All Reservations must be received by {date}.