ICGI '98 Payment Information Form

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ICGI'98 (July 12-14, 1998) Registrant Payment Information

Registrant Information

First Name  : ____________________________
Last Name   : ____________________________
Telephone   : ____________________________
FAX         : ____________________________
email       : ____________________________
Affiliation : ____________________________

Payment Information

 Check       : Amount = US $ ___________ 

 Credit Card : 

         Mastercard ________________________ 

         Visa       ________________________ 

         Discover   ________________________ 

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Please print this payment information form and mail / fax to along with a check (if applicable):