Center for Energy, Environment and Economics

(Please print out and complete this form and fax it to 516-686-7662 or mail to
Energy Shock Registration, c/o Jeff Morosoff, NYIT, PO Box 8000, Old Westbury, NY 11568)

Name________________________________________________________

Company_____________________________________________________

Address______________________________________________________

e-mail _______________________________________________________

Please List Attendees: ____________________________________

__________________________________________________

______________________________________________________

_____________________________________________________

Individual Tickets (registration before May 29, 2008) $75

Individual Tickets (registration after May 29, 2008) $85

NYIT Faculty and Staff, and Not-for-Profit Agencies $50

Student (with I.D.) $35

Amount to be charged to credit card__________________________

________Visa ______MasterCard ________Amex

Account #____________________________________________________

Exp. Date:______________________ 3-Digit Security Code ___________

Signature____________________________________Date:_____________

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The Center for Energy, Environment, and Economics, New York Institute of Technology,
Schure Hall, Old Westbury Campus, Northern Boulevard, Old Westbury, NY 11568-8000

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