Enrollment Form for Avian Flu Multi-Client Service
Service Enrollment Fee (U.S. Dollars -
covers 4 months of service
):
$ 6,000 for large commercial organizations;
$ 4,500 for non profit and public health organizations
YES! I wish to enroll in the bio-era Multi-client Service "Thinking Ahead: Anticipating Early Impacts of an Avian Influenza Pandemic."
Please send me an invoice
Organization Type
--Select one--
Commercial Organization
Non-profit organization
Government Agency
Multi-lateral Agency
Academic/Research Institute
Individual researcher
Other
Please register me for the Avian Influenze teleconference on March 9, 2005 at 1:00 pm e.s.t. -- and send me dial-in information.
Please have someone contact me with more information
Salutation
-- None --
Mr.
Ms.
Mrs.
Dr.
Prof.
Ing.
First Name
Last Name
Title
Company
Website
Email
Phone
Address
City
State / Province
Zip
Country
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