2008 DUKE CNSCR
Conference Registration

Name: __________________________________

Degree_________________________ Title:___________________________

Mailing Address:
_____________________________________________
_____________________________________________
_____________________________________________

Phone: ____________________________
Fax: ______________________________
Email: ____________________________

Method of payment (circle one):
Check Enclosed
VISA
MasterCard

Mail or fax completed form with credit card information or check
(payable to Duke University Medical Center) to the address below:

14th Annual Duke Nicotine Research Conference
Attn: Anne Marie Jacobs
2424 Erwin Road, Suite 201
Durham, NC 27705

Tel: (919) 668-5055
Fax: (919) 668-5088