REGISTRATION FORM for UMDNJ Master Educators' Guild/IAIMS Symposium, May 3, 2002
Course Code:  02MN25

First Name, Last Name and degrees:________________________________________________________

Phone:_____________________  Fax: _____________________

E-mail:___________________________ 

Department/School:_____________________________________________________________________

Address:______________________________________________________________________________

City/State/Zipcode:______________________________________________________________________

Site preference: ______Piscataway ______Newark (VTEL) _______Stratford (VTEL)

(For Piscataway attendees only):
Luncheon roundtable topic (indicate letters of first, second and third choices)__________________________
Afternoon concurrent session track topic 1: ________________________topic 2:______________________

Registration is free for all UMDNJ personnel, but advance registration is required by April 26, 2002.

Registration for non-UMDNJ personnel is free at the VTEL sites in Newark and Stratford, and $30 for attendance in Piscataway; advance registration is required by April 26, 2002.

___Enclosed is a check for $30 made payable to UMDNJ-CCOE.

or

___Please charge my:  ___Mastercard___VISA___American Express

Card Number: ___________________________________________

Expiration date:___________________Amount: $30

Card holder signature:________________________________

Registration Options:

• Mail:  Send completed registration form to:  UMDNJ-CCOE, P.O. Box 573, Newark, NJ 07101-3000 (UMDNJ address: UMDNJ-CCOE, ADMC 710, Newark campus) 
• Phone:  Call 973-972-4267 or 1-800-227-4852 to register and/or charge registration fee.
• FAX:  Transmit completed registration form to 973-972-7128.
• E-mail:  Send requested information to CCOE@umdnj.edu
• Online registration via secure server is available at: http://pluto.umdnj.edu/education/ConDisplay.asp?Formmode=Browse&IDD=466