Engaging Middle School Girls in Math and Science

Date ______________________________

Name _________________________________________________________

Address _______________________________________________________

City/State/Zip ___________________________________________________

Telephone ______________________________________________________

______ Check / M.O. ______ Purchase Order ______ Mastercard ______ Visa

______ $400 individual ______ $60 per person as a team ______ $40 college credit

Credit Card Number _________________________________

Name on Card _____________________________________

Expiration Date ____________________________________

Signature (required for credit card purchase): ________________________________________

Print and send this form by September 5, 2003, accompanied by check or credit card information to:

Please note:
· credit card information can be sent via fax to 617-332-4318, before faxing please contact 617-618-2920 and inform our staff that you will be faxing in your payment form
· do not send credit card information electronically
· do not send cash

Any questions? Call 617-618-2920