Name__________________________________________ Degree___________________

Affiliation (If applicable)_____________________________________________

Address_________________________________________________________________

________________________________________________________________________

City/State/Zip__________________________________________________________

Phone: _______________________________________ Fax______________________

E-Mail__________________________________________________________________



Please enroll me as a member of the Tomkins Institute   __ $45 

Friday Review Lecture _________________________________ $_______________

Conference Registration _______________________________ $_______________


                                                 Total: $_______________


__ Check Enclosed for $________ payable to the "Tomkins Institute" in US
   dollars.

__ I wish to pay by credit card (VISA or MASTERCARD only)

   Card Number _______________________________ Expiration Date __________

   Signature _______________________________________ (absolutely required)


Please send payment and completed application to:

Tomkins Institute Conference 
255 South 17th Street (Suite 2403) 
Philadelphia, PA 19103-6224 

1-800-317-1669 
Philadelphia and suburbs please call 1-215-546-1853 

www.behavior.net/orgs/ssti - julief@tomkins.org