Women in the Arts
November 10-12, 2011
University Missouri – St. Louis
One University Blvd.
265 General Services Bldg.
St. Louis, MO 63121-4400
314-516-4990-office
314-516-4992-fax
Wia@umsl.edu
www.umsl.edu/~wia/

 

 

Please return form with payment by October 20th .

Name: ______________________________________________________________________________

Institution/Organization: ______________________________________________________________

Address: ___________________________________________________________________________

City, State, Zip: ______________________________________________________________________

Phone: _____________________________________ Email: ________________________________

Payment Method:

Check #: ___________________________________ Amount: $_____________________________

Make checks payable to University of Missouri - St. Louis – and reference WIA Conference

Credit Card (choose one): MasterCard Visa Discover

Name on Card: ______________________________ Amount: $_____________________________

Number: ___________________________________ Expiration Date: ________________________

Payment covers the following - please check all that apply:

Registration: November 10 - $25 November 11 - $25 November 12 - $25 □ $65 for all three days

Display Table: Full Table - $20 Half Table - $10

DVD of all presentations: Available Spring 2012 - $ 20