Name ____________________________________________ Title___________________________
Business/ School Affiliation _________________________________________________________
Address _________________________________________________________________________
City _______________________________________ State __________ Zip Code _____________
Phone # _________________________________________________________________________
email address ____________________________________________________________________
Registration Fee (Select One):
____ $165: Standard Fee for Chicago ASA Chapter Members
____ $180: Standard Fee for non-Chicago ASA Chapter Members
____ $140: Fee for members’ early registration, applications postmarked before April 21, 2006
____ $155: Fee for nonmembers’ early registration, applications postmarked before April 21, 2006
____ $65: Fee for Students who are Chicago ASA Chapter Members
____ $71: Fee for Students who are not Chicago ASA Chapter Members
Payment Information:
[ ] Check or Money Order (please make payable to Chicago Chapter ASA)
[ ] Credit Card—Visa or Mastercard only:
Name on Card: ______________________________ Card Number: ______________________
Billing Address (if different from above): _______________________________________
_______________________________________
Expiration date: __________
Cardholder Signature: _______________________________________________
Mail form and payment to
Chicago ASA Conference
c/o Jerry Enenstein
222 Main Street
Evanston, IL 60202
For payment questions, please contact Jerry Enenstein at (847) 475-4403 or at JEResearch@ameritech.net
For additional conference information, please check the Chicago Chapter Website at:
www.chicagoasa.org or contact Lou Fogg at louis_fogg@rush.edu