Islam in America - Registration Form

6-7^th March, 2004 – Harvard Divinity School

First Name

Last Name

Title-Occupation

Institution

Phone Number

Mobile Number

Email

Address
City	State	Zip

Areas of interest

Pre-Registration Fee: (please check as appropriate) Cheque Number:

Ø Non-Student $20.00 Ø Student $15.00 Ø Harvard Student $10.00

Please complete and return with Registration Fee to address below
- must be received by 27^th February, 2004 to qualify for Pre-Registration Fee.
Additional $10.00 will be charged after 27^th February, 2004.

Thank you for your prompt registration.

See you in March!

Islam in America Conference

Harvard Divinity School

45 Francis Avenue

Cambridge, MA 02138