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Ultra Long Duration Ballooning Technology Workshop
NASA/Goddard Space Flight Center
June 24 and 25, 1997

REGISTRATION

If you are running a browser that does not support forms, please send e-mail to: Mary Hurlbut and request an ASCII text version of this form.
Please fill in the blanks below and check the appropriate boxes.

If you require assistance, send email to: Mary Hurlbut. You will be notified by mail once your registration has been completed.

  1. e-mail address:
  2. Full Name (First MI. Last):
  3. Affilication:
  4. Address:
    • Street Address:
    • City, State, Zip:
    • Country:
  5. Phone Numbers:
    • Work Phone (w/area code):
    • FAX Number (w/area code):
  6. Are you a United States Citizen?
    Yes
    No

    If "No", please state your citizenship:

    1. Green Card number:
    2. Visa number:
  7. Please indicate if you would like to make a presentation.
    Please enter a topic:

PAYMENT INFORMATION:

There is a $15.00 registration fee. Please note how you wish to pay.
Please make checks payable to "Jorge Scientific Corporation"

Check, Cash, or Credit Card

If you wish to pay by credit card, please print this form and send via facsimile to Mary Hurlbut at (301) 220-1704.

Card #:________________________________ Exp. Date:_______________________

Signature:_________________________________________________________


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Goddard