Computer History Museum - 2001 Fellow Awards Banquet

Computer History Museum
2001 FELLOW AWARDS BANQUET

Individual Seat Reservations

Please register using this form. Payment information can not be submitted online for security reasons.An individual reservation for each guest must be submitted. Kindly reply by October 15, 2001 . This is currently not a secure site. Please print completed form and mail, fax, or phone in your reservation. Reservation submission information below. Individual tickets are $175.00 per person.

*Name and Contact Information ( indicates required information)**
(One person per form please)
Last Name:*
First Name:*
Name, as you would like it to appear on your banquet badge:
Mailing address: *
City: *
State: *
Zip: *
Country: *
Home Phone:*
Email:*
Affiliation:
Other Phone:
Please select a dinner entree

Reserve a seat
Yes, I would like to reserve a seat for Computer History Museum 2001 Fellow Awards event.
	Individual Seat $175
Payment Method
This is currently not a secure site. Reservations may be submitted by fax, phone, or mail. Print out the information requested after you submit the form. If you are not submitting on line then please provide the information below. Credit Card Type: _____________________________ Credit Card number: ___________________________ exp. date (MM/YY): _________ amount authorized: _________ name as it appears on card: _____________________ signature: ___________________________________

Submit Reservation
Please submit reservation form no later than October 10, 2001. This is currently not a secure site. Reservations may be submited on-line, by fax, phone, or mail. Registration confirmation and a receipt will be sent to you prior to the event.

Online:	After you submit your information, please print out the payment information request and mail , fax, or phone in the payment information.
By Fax:	Print these.shtmls and fax them to: +1 650 604 2594 (credit card authorization required)
By Phone:	Call +1 650 604 2714 (credit card authorization required)
By Mail:	Please print these.shtmls and mail them to: Fellow Awards 2001 Registration Computer History Museum P.O. Box 367, Moffett Field, CA 94035, USA

Your donation in excess of $100 per person is a tax-deductible contribution. Federal ID# 77-0507525