have read and agree to the Facility Rules of
To register, please provide the information requested below:
*Required Field Name First: Mid: *Last: *Address: Address 2: *City: *State: *Zip: *Phone: *Email: Branch of Service:
ArmyAir ForceMarine CorpsNavyCoast GuardIf civilian, please specify connection/interest:Service:Vietnam Unit(s): Dates: Rank:Check if you hold any of the following awards:MOHDSCSSPOW Medal*Will you be there for the entire conference? YesNoIf not, which days will you attend? MondayTuesdayWednesdayThursdayIf you are requesting a room:Would you like a dormitory room?YesNoIf yes:Single - $350 (includes conference fee)Double - $290/per person (includes conference fee)Would you accept a double if space is limited?YesIf you are not reserving a room, but will attend the conference:Main conference room ($20/day)Main conference room ($50 for the entire conference)Satellite classroom ($10/day)Satellite classroom ($20 for the entire conference)I prefer the main auditorium.A satellite classroom will be acceptable to me.Please provide credit card information or use PayPal to secure a room, and/or to pay conference fees:Note: Your credit card information will be sent by unsecured email.If this makes you uncomfortable,or if you just have questions, please telephone Steve Sherman at (713)683-9076.
I will telephone Steve Sherman at (713)683-9076MasterCard, or Visa Name: Number: Exp. Date:PayPal (We haven't got the paypal button working yet. Please go ahead and send this form, then telephone Steve Sherman at (713)683-9076 for paypal instuctions.)
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