Second International Conference on 
Functional Mapping of the Human Brain
June 17-21, 1996

Name____________________________________________________________________
             Last                  First                       M.I.                           
Institution___________________________________________________

Street Address________________________________________________

City___________________State_____________Postal (Zip) Code________

Country____________________________________________________

Phone_________________FAX_______________Email______________

Registration Fees*:		Before February 1st	 Before May 27	At the Door
Regular			        $250		         $300	        $400

Student 			$150		         $175           $200
(Subject to eligibility)
							Total Enclosed___________

*Space is limited and early registration is advised.  Register before February 1st,
 1996, at significantly reduced registration fees!  Registration and payment are
 accepted on a first come, first serve basis.  If the registration capacity is
 reached, registration at the time of the meeting may NOT be possible.    

Conditions of Cancellations:
Registration cancellations made up to one week prior (June 10) to the start of the
conference will be fully refunded minus $50 for processing fees.

Student Eligibility:
I certify that the above named student is presently enrolled in this University and
working toward a degree.
	
	Name (Please Print)________________________________
	Affiliation________________________________________  
	Address__________________________________________  Phone__________________
	Signed_______________________________________________
		               (Department Head or Faculty Advisor)

Payment:

___ Check in US dollars to the order of  "Organization for Human Brain Mapping" .
	
___ Visa/Mastercard
		Acct #_____________________________Exp Date________

		Signature_________________________________________

Mail to:	      
Organization for Human Brain Mapping 			or FAX to
220 Longwood Ave					(617) 432-0057
Goldenson  B-231
Boston, MA   02115  USA