Return to Seaborg Symposium 2005
| Number of Attendees | Sub-Total_____Symposium |
| Symposium | No Charge |
| _____Medal Dinner* | $ 60 per person __ |
| _____Dinner Tables of Eight | $ 450 __ |
| ____ Student Dinner Support** | $ 50 per student __ |
| I/We am/are unable to attend, but enclosed is acontribution of $_______ to help support the work of the UCLA Department of Chemistry and BiochemistryTotal amount enclosed $______ | |
| Please make check payable to UCLA Foundation | |
**Student dinner support is fully tax deductible.
*Dinner Attendees only - $30 is tax deductible.
| Name__________________________________ |
| Title/Organization ________________________ |
| Address ________________________________ |
| City, State _______________________________Telephone_______________________________ |
| E-mail __________________________________Names of Symposium Guests:_______________ |
| _______________________________________Please send your check and form to: |
| Seaborg Event |
| Department of Chemistry and Biochemistry |
| UCLA |
| P.O. Box 951569 |
Los Angeles, CA 90095-1569 |
| Please respond by 10/15/05 Appeal Code: LS004 |