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Registration Form

36th Mid-Atlantic Macromolecular Crystallography Meeting

Due: May 11, 2006 (if at all possible)
Registration fee: $50
Please make your check payable to 36th Mid-Atlantic Crystallography Meeting and send it to:

Ms. Misty Allen
Center for Structural Biology
Wake Forest University Health Sciences
Medical Center Boulevard
Winston-Salem, NC 27157

Please complete all required fields(*) and submit.

*Last Name

*First Name
   Middle Initial
*Organization

*Address Line 1

Address Line 2

*City
 *State (abbrev.)  *Zip Code
*E-Mail Address
  *Phone number

*Will you attend the June 1 dinner?   Yes No
*Will you attend the June 2 evening event?   Yes No
*Do you need a room in Polo Residence Hall?   Yes No
If yes, are you?   Male Female
Have you arranged for a roomate?   Yes No
If so, their name: If not, we will assign one.