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Registration Form 2007
OCTOBER 17-18, 2007
Marconi Conference Center
18500 Highway 1
Marshall, California 94940
http://www.marconiconference.com/

Registration Deadline: SEPTEMBER 15, 2007
Registration Fee: $50 (meals & lodging)
Contact Info: Hy Le
hyle@diabetes.ucsf.edu or 415/514-3734

Please complete the online registration form. We will email you the confirmation#.

Retreat Information | Recharge Form | Directions & Map | Q & A | Program Agenda

Personal Information (* Required Field)
Title: *
Gender: *
First Name: *
Last Name:*
Email:*
Telephone: * - -
Department: *
Address: *
City: * State: *
Zip Code: *
Country:
If you're a Postdoc Fellow or student, please complete below:
PI's Name:
PI's Email:
Will you present a Poster? Deadline: September 15, 2007

Yes (please provide the title of your poster below):

No

Lodging Information:

Do you need to stay overnight? Note: First-come/first-serve basis.

Yes (please list the order of roommate preferences below)

1.

2.

3.

No

Emergency Contact Information (* Required Field)
In case of EMERGENCY, please notify:
Name:*
Relationship:
Daytime Phone: *
Evening Phone: *
Payment Method (* Required Field)
How would you like to pay for the registration fee? *

Check (Make check payable to UCSF Regents & mail it to)

UCSF Diabetes Center
C/O An Chau
513 Parnassus Ave., Box 0534
San Francisco, CA 94143-0534
Tel#: 415.476.1609 Fax#: 415.731.3612

UCSF Recharge (download Recharge form below)

>> Recharge Authorization Form <<

Request waiver (Note: We'll waive fee case-by-case basis.)

Retreat Information | Recharge Form | Directions & Map | Q & A | Program Agenda