• Print this form (or download the MS Word version)
• Fill it in
• Fax it to (814) 732-2611
• or mail it with your payment to
  Postcards from the Future
  c/o University Honors Program
  Edinboro University of Pennsylvania
  Baron-Forness Library, 7th Floor
  Edinboro, PA 16444 USA

Name: ______________________________________________________________

(as you want it to appear on your badge)

Institution: _______________________________________________________

Address: ___________________________________________________________

City: ______________________________________________________________

State/Province: ____________________________________________________

ZIP/Postal code: ___________________________________________________

Country: ___________________________________________________________

Telephone: _________________________________________________________

Fax: _______________________________________________________________

Email: _____________________________________________________________


The keynote luncheon includes seasoned chicken breast and chocolate
 eclair for dessert. Regular coffee, decaf, lemonade and water will
 be available. If you have any dietary restrictions (vegetarian,
 kosher, etc.), please indicate here:

___________________________________________________________________

___________________________________________________________________


Special accessibility or equipment (projectors, power point, etc.)
 requirements:

___________________________________________________________________

___________________________________________________________________

Please circle appropriate registration fee. All prices are in US currency:
		Prior to March 15th	After March 15th
	Student (presenter) with valid ID	$25	$35
	Student (attendee) with valid ID	$25	$35
	Presenter (non-student)	$60	$75
	Attendee (non-student)	$40	$50

Type of payment:

[  ] Check (payable to Edinboro University Honors Program)
[  ] Money Order
[  ] VISA
[  ] MasterCard
[  ] Discover
[  ] American Express

Total amount: $ _______________________

Card number: ________________________________ Exp. date: _________________

Print name as it appears on card: 

__________________________________________________________________________

Signature: _______________________________________________________________

Billing address if different from above 

__________________________________________________________________________

(for authorization purposes)