as you wish to have it printed on your name badge
SCHOOL OR ORGANIZATION JOB TITLE
STREET ADDRESS CITY STATE ZIP
EMAIL ADDRESS FOR REGISTRATION CONFIRMATION AREA CODE TELEPHONE NUMBER
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I WILL BE ATTENDING: AFTERNOON ACTIVITIES
EVENING BANQUET $45
No refund requests will be hono
red after May 29, 2013.
MAKE CHECK OR MONEY ORDER PAYABLE TO:
University of Wisconsin–Madison
The most secure way to make payment is by credit card online at:
If you prefer to make your credit card payment using this form, please complete the following information:
Credit Card Information
Please charge my payment of $45 for the banquet to:
EXPIRATION DATE MO/YEAR 3 OR 4 DIGIT SECURITY CODE
CARD HOLDER NAME AS IT APPEARS ON YOUR CREDIT CARD SIGNATURE
ADDRESS WHERE YOU RECIEVE THE BILL
FOR THIS CARD CITY STATE ZIP
Required for both afternoon and evening. Registration payment deadline is May 29, 2013
PLEASE PRINT or REGISTER ON-LINE AT:
FESTSCHRIFT REGISTRATION FORM