Coastal Engineering Today
Registration Form

Either mail:    Department of Civil Engineering           
Johns Hopkins University
3400 No. Charles Street
Baltimore, MD 21218

or Fax: 1 410 516 7473
       Please Print:

       Title and Name:_______________________________________________________

       Affiliation:___________________________________________________________

       Address:_____________________________________________________________

       Address:_____________________________________________________________

       City, Country and Mailcode_____________________________________________

       Email address:_________________________________________________________

       Phone Number:________________________________________________________

       Fax number:___________________________________________________________
       Registration fee:  $250 U.S.        Additional Dinner Tickets: ______  @ $40
                                                             Additional Icebreaker Tickets: ____@ $10

        I will pay by credit card [  ], or  check [  ] ($USD drawn on a U.S. bank payable to Johns Hopkins
        University),  or on-site with cash [  ].

        For credit card payment, fax this form to 1-410-516-7473 or
        for personal attention,  call 1-410-516-8680 .

        Credit card type:  Mastercard [ ]   Visa [ ]

        Credit card number:___________________________________________Expiration Date:___________

        Card holder's name (if different from above)______________________________________

        Address (if different from above)_______________________________________________

        Address ___________________________________________________________________

       Card holder's  signature________________________________________