Dinner Lecture - PHILLIPS OLD COLONY HOUSE, BOSTON, MA - Registration Form

Typhoid Mary - Tuesday, January 23, 2001

Name: _________________________________________________________________

Facility: ________________________________________________________________

Address: ________________________________________________________________

Phone: _________________________________________________________________

Registration Fee:  $30 (members) ____/ $35 (nonmembers) ___/ $10 (full-time students)

Payable to:  NORTHEAST BRANCH - ASM
Mail to: Jo-Ann Rosol-Donoghue, 33 Lancaster Terrace, #102, Brookline, MA 02446
Due by January 15, 2001 (Also, cancellations must be received by this date for refund.)

Please print this form out, fill in required information, and mail with check to above address.