I have read and agree to the Facility Rules of Simmons College

To register, please provide the information requested below:

 *Required Field
     Name  First:  Mid: *Last: 
        *Address: 
       Address 2: 
           *City:  *State:  *Zip: 
          *Phone: 
          *Email: 

Branch of Service:
Army
Air Force
Marine Corps
Navy
Coast Guard
If civilian, please specify connection/interest:

Service:
Vietnam Unit(s):
          Dates:
           Rank:

Check if you hold any of the following awards:
MOH
DSC
SS
POW Medal

*Will you be there for the entire conference? 
Yes
No

If not, which days will you attend?  
Monday
Tuesday
Wednesday
Thursday

If you are requesting a room:


Would you like a dormitory room?
Yes
No


If yes:

Single - $350 (includes conference fee)
Double - $290/per person (includes conference fee)

Would you accept a double if space is limited?
Yes

If you are not reserving a room, 
but will attend the conference:

Main conference room ($20/day)
Main conference room ($50 for the entire conference)
Satellite classroom  ($10/day)
Satellite classroom  ($20 for the entire conference)

I prefer the main auditorium.
A satellite classroom will be acceptable to me.

Please provide credit card information or use PayPal 
to secure a room, and/or to pay conference fees:

Note: Your credit card information will be sent by unsecured email.
If this makes you uncomfortable,or if you just have questions, 
please telephone Steve Sherman at (713)683-9076.
I will telephone Steve Sherman at (713)683-9076
MasterCard, or Visa
    Name:  Number:  Exp. Date:

PayPal (We haven't got the paypal button working yet. 
Please go ahead and send this form, 
then telephone Steve Sherman at (713)683-9076 
for paypal instuctions.)


If you do not receive an acknowledgement
when you press the "Send" button, 

then your form was not sent. 
Please call Steve Sherman at (713) 683-9076.