FORM MUST BE TYPED.

To register, payment must accompany your registration form. No registrations will be processed without payment. Checks must be payable in US funds. Please send your registration form and payment to:

G Corp.
PMB 221, 738 Main Street
Waltham, MA 02451

or fax them to: (781) 466-9988

Incorrect or Fraudulent Information: A credit card transaction may be canceled by G Corp, the organizer of the AGBT conference, if we reasonably determine that the registration information you provided is incorrect or fraudulent, or if we reasonably believe the credit card utilized is from an unauthorized party.

Cancellations: To cancel your conference registration, please notify the G Corp office in writing by mail or by fax at 781-466-9988. Registration cancellations postmarked and paid prior to January 8, 2010 will be fully refunded, less a $200.00 processing fee. Substitutions are not allowed. There will be no refunds after January 8, 2010. All refunds will be processed after the conference.

Check Payments: If paying by check, the check must be payable in US funds and received within 10 business days of registration or the registration will be canceled.

Commercial Attendees: There is a limit of 10 attendees per commercial organization (including subsidiaries and affiliates). If your registration exceeds the limit for your organization, you will be notified that your registration has not been accepted and your registration fees will be refunded.

Please type or print neatly.

Desired Registration Package: (Please select one.)

4 day package:

3 day package: (limited availability)

Pre-meeting Workshop : (No additional fee. Please select one.)

will attend:

will not attend:

Lodging Requirements: (Please select one.)

Single Occupancy:

Double Occupancy:

Double Occupancy Required Information: Full name of preferred roommate: ______________________ If you have not specified a roommate, we will assign a roommate for you. To assist us with a suitable match, please fill out the following questions:   Your sex: Male: Female:   If you wish to be assigned (when possible) with another attendee of similar circumstance, please identify yourself as one of the following:   Student: Faculty: Business:

Registration Information:

Last Name:

_________________________

First Name: ______________________

University/Institution/Company: ___________________________________________________

Department/Campus Mailing Address:  ______________________________________________

Street Address:

____________________________________________________________

City:

__________________________

State/Province: __________________

ZIP/Postal Code:

_____________

Country:________________________

Telephone Number:

______ - ______ - _________

Fax Number:

______ - ______ - _________

E-mail Address (important for notices) ______________________________________________

Method of Payment:

Visa

MasterCard

American Express

Discover

Check payable to G Corp.

Credit Card Number: _______  _______  _______  _______

Credit Card Expiration Date: (mm/yy) ____ / ____

3-Digit (4-Digit for Amex) Verification Number (located on back of card): ____

Billing Address

Street Address: ___________________________

City: ___________________________

State/Province: ___________________________

ZIP/Postal Code: ___________________________

Country: ___________________________

Card Holder's Name:  (as it appears on the card) ___________________________

Card Holder's Signature: ___________________________

Amount paid: ____________________