NAME: ____________________________        NICKNAME FOR BADGE: _______________

ADDRESS:___________________________________________________________________

                   ___________________________________________________________________

                   Tel: _______________________                  Fax: _________________________

                   Email: ______________________________________________________________

_____ Full Program (Scientific & Social) includes all @ $150                  = _________

_____ Social Program only

_____ Opening Dinner @ $25                        ______ Picnic @ $15        = _________

           Names: ________________________________________________________

_____ Social Program only (children under 16) @ no charge

           Names: _________________________________________________________________

                                                                                                                         Total: $ __________

We have reserved a block of rooms at the University Inn @ $72/night and the Buffalo Marriott @ $89/night (has indoor/outdoor pool). If you require a hotel reservation please mark your selection below:

University Inn     ____ room(s) _____ person(s)  arrival date ________  departure date _______

Buffalo Marriott  ____ room(s) _____ person(s)  arrival date ________  departure date _______

Will you be parking a car on campus ____Yes  ____ No

Make check payable to University at Buffalo at Foundation and send it, with this form to:

                                            Buffalo Pharmaceutics Symposium
                                            SUNY at Buffalo, 517 Hochstetter Hall
                                            Buffalo, NY 14260-1200
                                            FAX: 716-645-3693

We look forward to seeing you at the symposium. Register now by fax, using this form, then forward your check by mail. It will help if you include a copy of your faxed form. Thank you!