Symposium Goodies Order Form
*
indicates a required field, i.e., form cannot be submitted unless these are filled in.
Name
*
Institution/
Company
Address
*
City/
province
*
State
*
Zip Code
*
Country
*
Phone
Fax
E-mail
*
Opera Video
($25 each)
VHS (NTSC - USA, Japan, elsewhere)
VHS (PAL - Much of Western Europe, including West Germany, Great Britain, Switzerland, etc.)
VHS (SECAM - France, much of Eastern Europe, former Soviet Union, and Middle East)
Beta
Picture(s)
($5 for first
of each,
$2 for each
additional of each)
Disk:
Photo:
Quanity:
Disk:
Photo:
Quanity:
Disk:
Photo:
Quanity:
Disk:
Photo:
Quanity:
Disk:
Photo:
Quanity:
Disk:
Photo:
Quanity:
Do you have any other comments?
for help click
here
.
After you have filled out and submitted this form, print it out and mail,
along with your check or money order (US dollars, please) payable to the American Peptide Society to:
American Peptide Society
c/o Anne Mockovak
University of Minnesota-Institute of Technology
1701 University Avenue SE, Room 106
Minneapolis, MN 55414
Phone number: 612-624-5881
If you want to pay by credit card, please fill in your card type, number, and expiration date as a comment in the appropriate space on this form.
