FRIDAY, JUNE 1, 2007, 8:30 A.M. ≠ 2 P.M.
DE SEVERSKY CENTER, OLD WESTBURY, NY 

(Please complete and fax this form to 516-686-7662 or mail to
Energy Shock Registration, c/o Jeff Morosoff, NYIT, PO Box 8000, Old Westbury, NY 11568) 

 

Name________________________________________________________

 

Company_____________________________________________________

 

Address______________________________________________________

 

e-mail _______________________________________________________

 

Individual Tickets (registration before May 29, 2007)                 $65

 

Individual Tickets (registration after May 29, 2007)                    $75

 

NYIT Faculty and Staff, and Not-for-Profit Agencies                   $50

 

Student (with I.D.)                                                                $35                                                     

 

Amount to be charged to credit card__________________________

 

________Visa       ______MasterCard                  ________Amex

 

Account #____________________________________________________

 

Exp. Date:______________________ 3-Digit Security Code ___________

 

Signature____________________________________Date:_____________