DIMACS Workshop Registration Form

                    DIMACS Workshop Registration Form
             MiniWorkshop on the Mathematics of Drug Discovery
			   September 21-22, 1995
     

Name:  ..................................

Title:  .................................

Affiliation:  ...........................      Student?  .............

Address:  ...............................

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Phone:  .................................

Fax:  ...................................

Email:  .................................

Talk title/topic:  .....................................................

Will you want to give a software demo?  Yes ....  No ....  Maybe  ......

Other special needs: ...............................................