2007 Seaborg Symposium and Dinner Registration Form

R. Stanley Williams biography/ Program of Speakers/ Maps/ Registration Form/ About the Seaborg Symposium/ UCLA Alumni Website/ Department of Chemistry and Biochemistry

Number of Attendees
____ Symposium No Charge
____Medal Dinner $70 per person
($40 is tax-deductible gift)

____Dinner Tables of Eight $500 ($260 is tax-deductible gift)
____Student Dinner Support $50 per student (fully tax-deductible)

____1/We am/are unable to attend, but enclosed is a contribution
of $_____ to help support the work of the UCLA
Department of Chemistry and Biochemistry.
Visa____, M/C____, AMEX___, Discover___
Credit Card No.________________________
Date of Expiration______________________
Total amount enclosed $________________

Please make check payable to The UCLA Foundation

Name__________________________________
Title/Org_______________________________
Address________________________________
City, State______________________________
Telephone______________________________
E-mail_________________________________
Names of Symposium Guests:______________
______________________________________
Number of Dinner Guests: _________________
Names of Dinner Guests:__________________
______________________________________

Please send your check (or credit card information) and form to:


Seaborg Event
Department of Chemistry and Biochemistry
UCLA
P.O. Box 951569
Los Angeles, CA 90095-1569

or contact Cynthia Allen, Seaborg coordinator:

(310) 267-5123 or callen@chem.ucla.edu

Please respond by 10/19/07 Appeal code: LS058