Registration Form

        Name:        ___________________________________________________

        Address:    ___________________________________________________

        City:            ___________________________________________________

        State, Zip:    ___________________________________________________

        Phone:         ___________________        Email: ________________________

Fees (Including registration for the conference, refreshments, and lunch and the conference dinner on September 24th)
                □ $ 75
                □ $ 50 (Reduced Student Rate - please include photocopy of student ID)
                □ $ 95 for registrations after 09/20/11.

                □ I prefer vegetarian meals.

Enclosed is my conference fee:

                □ Check (payable to Merton Conference)

                □ Visa/MasterCard/American Express

        Credit Card Number: __________________________________________________

        Expiration Date:______________________________________________________

        3-4 Digit Card Verification Code:_________________________________________

       Cardholder's Name:____________________________________________________

       Cardholder's Signature:_________________________________________________

Please print and return this form to:
Paul M Pearson. Merton Conference,
Thomas Merton Center, Bellarmine University,
2001 Newburg Road, Louisville. KY. 40205.