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Mail-In Payment Form for the Nov 13, 2009, Baekeland Symposium Name:___________________________________________________________
Telephone: _________________ Institutional Affiliation: _________________________________________________________________________ Address: _____________________________________________________________________________________ Email:
_______________________________________________________________ Amount Enclosed: _______
Registration fee:
$75 (professionals);
$50 (retired or unemployed);
$25 (students).
Please make your check or money order payable to the
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