ESA - 89th Annual Meeting, August 1-6, 2004

ESA 89^th Annual Meeting – Portland, Oregon, August 2004
Abstract Submission Fee Form

Please complete each of the following items () or enter "N/A" if not applicable.

Section A: Abstract Information:

NOTE: In order to properly apply the Abstract Submission Fee accompanying this form, we need to know for which abstract the payment is being paid. Please complete the following items as they pertain to that abstract only.

Abstract Submission Reference Number:

(format must be 2 or 3 letters, followed by 4 digits, followed by 6 digits; e.g., CRO-9215-123456)

Name of Primary Author:

Presenter Name:

Affiliation/Institution/Agency of Abstract Presenter:

Presenter Address:

City, State/Province:

Zip or Postal Code:

Country:

Daytime Telephone #:

(Area Code) xxxxxxxxxx

Fax Number:

(Area Code) xxxxxxxxxx

Contact Email Address:

(username@domain.com)

Abstract Type:

Oral Paper Organized Oral Session Paper
Poster Presentation Symposium Talk

Section B: Payment Information:

NOTE: This Form accepts payment by credit card (MasterCard or VISA only), ESA does not accept America Express, Discover, or Diners Club. Credit card charges cannot be processed unless an expiration date is provided.

Abstract Amount Paid:

$25.00 - Poster Presentation $40.00 - Oral/Symposium Talk

Payment Type (Credit Card):

Name as It Appear on Card:

Card Number:

(Number Only)

Expiration Date (MM/YY):