Registration Form

First Name:

Last Name:

Title: (Dr., Ms., Mr, etc)

School/Institution:

Mailing Address:

Street:

City:

State:

Zip:

Telephone:

E-mail:

Faculty Registration ($15): 0 1 2 3 4 5 6 7 8 9 10

Student Registration ($5): 0 1 2 3 4 5 6 7 8 9 10

Friday evening banquet with keynote speaker

Friday evening banquet with keynote speaker ($15): 0 1 2 3 4 5 6 7 8 9 10

Special dietary needs: Please mark number of meals (number of attendees)

None 0 1 2 3 4 5 6 7 8 9 10 Vegan 0 1 2 3 4 5 6 7 8 9 10 Vegetarian 0 1 2 3 4 5 6 7 8 9 10 Other (Specify Type)

If you wish to pre-pay, you can mail a check or money order to:

Rose State College
Attn: Business Affairs 
6420 S.E. 15th Street.
Midwest City, OK 73110-2799

Please include a memo or letter to direct our cashiers to deposit into department 37-161

Checks should be made to "Rose State College" with "State AOK Physics" on the memo or commentary space.