REGISTRATION FORM
Sixteenth International
Conference on Cognitive and Neural Systems
May 30–June 2, 2012
Department of
Cognitive and Neural Systems
Fax: +1 617 353 7755
Mr/Ms/Dr/Prof:_____________________________________________________
Affiliation:_________________________________________________________
Address:__________________________________________________________
City, State, Postal Code:______________________________________________
Phone and Fax:_____________________________________________________
Email:____________________________________________________________
The registration fee
includes a copy of the conference proceedings volume, a reception on Friday
night, and 3 coffee breaks each day.
CHECK ONE:
( ) $150
Conference (Regular)
( ) $95 Conference (Student)
METHOD OF PAYMENT:
[ ] Enclosed is a check made payable to "
Checks must be made
payable in US dollars and issued by a
[ ] I wish to pay by credit card
(MasterCard, Visa, or Discover Card only)
Name as it appears on the
card:___________________________________________
Type of card:
_____________________________ Expiration date:________________
Account number: _______________________________________________________
Signature:____________________________________________________________