HSI CONFERENCE 2004
REGISTRATION FORM

Standard Registration Fees in 2004:
Attendee $200
Spouse $180
Please make checks payable to HSI Conference 2004 in US currency.

Please print this page and fill it out.

If paying by credit card, please fill in your credit card information and
fax the completed form to Endre Guttmann at 517-207-6743.

If paying by check, please make your check (US funds) payable to HSI Conference 2004 and
mail the completed form, with your check, to:

Endre Guttmann
11-J, Cond. Villas del Mar, West
Carolina, Puerto Rico 00979

ATTENDEE (PROF/DR/MR/MRS/MS)_________________________________


ORGANIZATION_________________________________________________


ADDRESS LINE 1_______________________________________________


ADDRESS LINE 2_______________________________________________


ADDRESS LINE 3_______________________________________________


TELEPHONE____________________________________________________


FAX__________________________________________________________


E-MAIL_______________________________________________________


ARRIVAL DATE/TIME____________________________________________


DEPARTURE DATE/TIME__________________________________________


SPOUSE NAME (PROF/DR/MR/MRS/MS)______________________________


AMOUNT PAID__________________ DATE OF PAYMENT________________


CHECK NUMBER_________________________________________________


CREDIT CARD: AMEX:____ VISA:____ MASTER CARD:____ DINERS:____


CARD HOLDERS NAME:___________________________________________


CARD NUMBER:_________________________________________________


EXPIRATION DATE______________________________________________


CARD HOLDER'S SIGNATURE______________________________________