CONFERENCE REGISTRATION FORM
Due: July 5, 2005
Name: _______________________________________________________________
Affiliation: _______________________________________________________________
_______________________________________________________________
( ) If Graduate Student, please check.
Mailing Address: _______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Office Telephone: _______________________________________________________________
Home Telephone: _______________________________________________________________
(optional)
Registration Fee . . . . . . . . . . . . $ 100.00* Graduate Student Fee . . . . . . $ 65.00
(includes Keynote Dinner) (includes Keynote Dinner)
Membership Dues . . . . . . . . . . 50.00 Membership Dues . . . . . . . . 25.00
________ ________
Total Due . . . . . . . . . . . . . . . . . $ 150.00 Total Graduate Student Due . . . $ 90.00
*If your spouse or partner+ also wishes to attend, the joint cost of Registration and Membership is:
$ 150 --- Primary Registration (includes 2 Keynote Dinners) +If paying only for the Keynote
50 ---- Secondary Membership Dinner, the extra cost is $40. Your
_________ spouse or partner only will be allowed
$ 200 --- TOTAL DUE (a savings of $50) to attend your presentation panel and
not the complete conference.
Mail completed form and check (payable to The Jungian Society) to:
Barbara A. Silliman, Coordinator
P. O. Box 19722
Johnston, RI 02919-0722