Information for Members of GLIPS

Please print out, fill in and return this form, along with your check, payable to the Greater Long Island Psychiatric Society, no later than September 30, 2008.

No telephone reservations can be accepted.

Name______________________________________________

Address____________________________________________

Phone Number______________________________________

E-Mail Address______________________________________

		Total
GLIPS Members-in-Training only	___@ $25.00/person	_____
General Members, Fellows, Other MTs, Residents and Guests	___ @ $75.00/person	_____
Non-Members and their Guests	___ @ $100/person
*Total Amount Enclosed*	______	_____

Greater Long Island Psychiatric Society
P.O. Box 287, Lakehurst, NJ 08733
732-408-9650 fax: 732-408-9652

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