MODERNIST STUDIES ASSOCIATION 5^th ANNUAL CONFERENCE

MSA 5

September 25th–28th, 2003

Birmingham, UK

Duplicate as needed.

A separate form must accompany each registration.

REGISTRATION FORM:

Name Badge Name

Affiliation Address

City, State Zip/Country

Telephone ( ) Fax ( )

E-Mail

Conference Registration includes Thursday Welcome Reception; refreshment breaks; and conference materials.

Before August 15^th After August 15^th

Full Conference Registration:

Faculty Registration £ 85.00 £105.00 £ __________

Student/ Adjunct Registration £ 65.00 £ 85.00 £ __________

TOTAL ENCLOSED £

Method of Payment: ž Check or money order ž Visa ž Mastercard ž AmEx

(payable to University of Birmingham)

If credit card, Cardholder Name:

Account #: Expiration Date:

Signature (for credit card):

Send Registration Form (and fees) to: Modernist Cultures

ATTN: Samantha Skinner

Department of English

The University of Birmingham

Edgbaston

Birmingham B15 2TT

United Kingdom

 Please indicate any special dietary or access needs:

Please note that MSA membership dues should be sent to Johns Hopkins University Press.

For further information contact: Samantha Skinner sjskinner@yahoo.com