Partner Registration Form

The Biotechnology Roundtable Partner Registration Form (Churchill Club Discount Code: gBRT)

Purchase of One Seat for October 21^st, 2003, 6:00 PM, Biotech Impact 2003: The Shape of the Industry at Hyatt Rickeys Palo Alto, 4219 El Camino Real Palo Alto, CA 94306 Hotel Telephone: (650) 352-1234

PLEASE PRINT & FAX THIS FORM TO (408) 558-1635

Name (First, Last):

Title / Company:

Telephone:

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Cost: $40.00 - Credit Card Type (Circle): Visa / MasterCard / AMEX

Credit Card Number:

Expiration Date:

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Signature: _______________________________ Date: _________________

The proceeds of this sale go directly to the Churchill Club. The Biotechnology Roundtable does not provide confirmations or refunds. For information regarding the Churchill Club please visit www.ChurchillClub.org or call (408) 558-3636.