PIUG - 2004 North East Workshop Registration (Secure)

Your Information

First Name:
Last Name:
Company/Affiliation Name:
Department Name:
Attention To:
Address Line 1
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City:
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Postcode/Zipcode:
Country:
Email Address:
Confirm Email:
Telephone:	**Please include country and area codes
Facsimile	**Please include country and area codes

PIUG Membership (renewed for 2004?)	Yes No

An ice cream social might be held immediately following the meeting, if there is enough interest;	I would like to attend the ice cream social
Do You Require Wheelchair Access?	Yes OR No
PayPal Account Name (Please enter the PayPal Account Name that you will be using to make this payment. This is required for verification of order form and PayPal payment)
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