NOTE: This site is an historical archive, to be kept indefinitely.

[ Program ]
[ Conference Objectives ]
[ Organizing Committee, Participants, and Intended Audience ]
[ Bibliography ]
[ Registration Form ]
 
 

Registration Form Download

If you have Adobe Acrobat Reader, download and print the PDF version:

Download the PDF Conference Registration form by clicking on the link to the right---------------------->

 (85k download Registration Form )

OR -- Print this page, fill out, then mail it to the address below.Please don't forget your signature at the bottom if paying by credit card.

The Registration Fee is US$125.00 in advance, or $150.00 for on-site registration the day of the Conference. Registration includes admission, program and syllabus, and breakfast and lunch for both days of the Conference. The Registration Fee is payable to the Department of Psychiatry, NYU School of Medicine in the form of a check drawn a US bank, or using a credit card as indicated below.

Last Name First Name Middle Initial Degree

Organization or Academic Affiliation

Street Address

City State ZIP or Postal Code

Country

Phone number FAX number

E-mail Address

[ ] Payment by Check -- Please make payable to: Dept. of Psychiatry, NYU School of Medicine

[ ] Credit Card Payment [ ] Visa [ ] MasterCard [ ] American Express

Name as it Appears on Card

Credit Card Account Number

Expiration Date (month/year)

I agree to the payment of US $125.00 to the Department of Psychiatry, NYU School of Medicine, for registration for the Conference on Ibogaine.

Signature: ___________________________________________

Do you require any individual accomodation due to a disability? If so, Check here [ ] and please provide a description as an attachment.

Completed Registration Forms should be sent to:

Kenneth Alper MD, Director, Conference on Ibogaine
New York University School of Medicine
Brain Research Laboratories
8th Floor Old Bellevue Administration Building
462 First Avenue
New York, NY 10016
Phone: (212) 263-6287 FAX: (212) 263-6457

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