Symposium Registration

Annual Neuroscience Symposium Registration

We are not able to accept online payments. Please remit your registration payment (cash or check) separately from your online registration by October 22nd, 2012 to:

Dr. Brian McMillen, ECCSFN Treasurer
Department of Pharmacology & Toxicology
Brody School of Medicine, 6S-10
600 Moye Blvd.
Greenville, NC 27834

Email: mcmillenb@ecu.edu

Please note the following before you submit this registration form:

If paying by check, please make it payable to:
"Medical and Health Foundation of ECU" with "ECCSFN" in the memo line.
Late registration and payment will still be accepted at the door.
You will be notified via email upon receipt of payment. If you do not receive any notification within 3-5 days, please contact Dr. McMillen.
All fields indicated with "*" are required.

Name*:

Degree(s) Earned*:

If not applicable, then enter "N/A"

Dept/Org*:

Institution/Company*:

School/Work Address*:

Email*:

Phone*:

If outside of 252, then please include area code.

Registration Type*:

Faculty ($10)

Guest ($10)

Staff ($10)

Postdoc ($5**)

Resident ($5**)

Graduate Student ($5**)

Undergraduate ($5**)

**If you are a presenter, then the registration fee is waived. Please indicate that you are a presenter in the Comments box.

Extra Credit

If you are a student and will be attending to earn extra credit for a course, then please check the box above and enter the instructor's name and course number in the Comments/Questions box.

Comments/Questions: