Registration Form

Where Wireless Technology and Business Converge

May 13 - 15, 2002
San Jose, CA

Registration Form

The amount we will charge to your credit card is: (circle preference)
Passport Pass (workshop plus conference, May 13-15) -- $1,295
Two day conference pass (May 14-15) -- $995
Workshop only (May 13) -- $695
Conference Day 1 only (May 14) -- $695
Conference Day 2 only (May 15) -- $695

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:
State or Prov.:
Zip/Postal Code:
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: INT Media Group, Inc. ("INTM") 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 INTM recording and/or photographing the event and using such items, including your likeness, in future promotions. INTM 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. INTM'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 INTM Media Group):

INTM Media Group
Att: Nanotech 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: Allison Alessio.

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