2004 National Obesity Prevention Conference

Sponsored by the United States Department of Agriculture

October 25-27, 2004
Hyatt Regency Bethesda
Bethesda, Maryland

Participant Information

Required fields are marked with an asterisk (*).

Title/Prefix*:

First Name*:

Last Name*:

Name for Badge (First name):

Position Title:

Affiliation*:

Street Address/P.O. Box*:

Suite/Mail Stop:

City*:

State*:

Zip Code*:

Phone*:

Fax:

E-mail*:

May we include your contact information on the conference participants list?* Yes No

Registration Type*
Regular registration (beginning October 1) = $400
Credentialed Press = no fee (no meals included)

Meal Functions*
The conference fee includes dinner on Monday evening, continental breakfast on Tuesday and Wednesday, and lunch on Tuesday,
as well as refreshments at breaks. Please indicate the meal functions that you will attend below.

Monday, October 25 - Dinner Yes No

Tuesday, October 26 - Luncheon Yes No

Special Accommodations
Please note any special accommodations that you may need (e.g. vegetarian or kosher meals, assistive listening device, braille or large print materials, sign language interpreter, etc.)

Payment Information*

Credit Card (select type):

VISA MasterCard Diners Club American Express

Credit Card Number

Expiration Date (Enter as MM/YY)

Cardholder's Name

Cardholder's Telephone Number

Cardholder's Fax Number

Cardholder's E-mail

Check: made payable to "Graduate School, USDA". Fed. ID 53-019-6561. Print this form and mail it with check to:
National Obesity Prevention Conference, Graduate School, USDA, 600 Maryland Avenue, SW (IH), Washington, DC 20024

Purchase Order/Training Form: Print this form and mail it with authorized purchase order or training form to:
National Obesity Prevention Conference, Graduate School, USDA, 600 Maryland Avenue, SW (IH), Washington, DC 20024

Press: No fee registration for credentialed press. No meals are included.

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