Registration Form

November 18 - 19, 2002
The Puck Building
New York, NY
Registration Form

The amount we will charge to your credit card is: (circle preference)
Full Pass - November 18 - 19 - $995.00
Day 1 - November 18 - $695.00
Day 2 - November 19 - $695.00
Exhibit Hall & Venture Capital Pitch Forum Pass - Free in Advance ($25.00 at the Event

Please complete the form below. After typing information,
print this form and mail or fax with payment to the address below.

YOUR INFORMATION
First Name:
Last Name:
Title:
Company Name:
Street Address:
City:
United States or Canada:
Zip/Postal Code:
Province:
Country:
E-mail Address:
Providing your e-mail address to us indicates that you may be interested in receiving future e-mail promotions about other INTM events. Check to opt-out*
Telephone:
Fax:

PAYMENT INFORMATION
Credit Card Holder's Name:
*Credit Card Type:
Credit Card Number:
Month card expires:
Year card expires:
Cancellations and Substitutions If you must cancel for any reason, you must notify us in writing 30 days prior to the event for a refund less a $100 processing fee. Cancellations within 30 days of the event are non-refundable. You may transfer your registration to another person at any time by providing written authorization. Please Note: Jupitermedia Corporation reserves the right to make changes to the events program. Unforeseen circumstances may result in the substitution of a presentation, topic or speaker. You consent to Jupitermedia Corporation recording and/or photographing the event and using such items, including your likeness, in future promotions. Jupitermedia Corporation reserves the right to reject or rescind any registration and return any fees accordingly. Registrant assumes all risks incidental to participation in all event activities, including loss or damage to property. Jupitermedia Corporation's total liability shall be limited to the amount of fees received, if any, from a particular registrant.
How did you hear about us?:
If other:

Mail your completed registration form with payment to (checks payable to Jupitermedia Corporation):

Jupitermedia Corporation
Att: Nanoelectronics Planet Conference
Church Street Station
P.O. Box 6414
New York, NY 10249-6414

You may also fax it WITH CREDIT CARD PAYMENT to (203) 286-1010 - ATT: Registration Department.

NOTE: REGISTRATION FORM AND PAYMENT MUST BE RECEIVED TOGETHER TO BE PROCESSED.