Registration Payment with Check, Money Order, or Credit Card Registration: $60 Faculty price: $10 Student price: $5 Faculty and students at Azusa Pacific University can register for free. ______________________________ Print and fill out the form below to be sent by mail or fax Open Theology and Science Conference c/o Dan Messier Eastern Nazarene College 162 Old Colony Road Quincy, MA 02170 Fax: (617) 847-5933 First Name:     _______________________________________ Last Name:     _______________________________________ Mailing Address:         _______________________________________ City, State, Zip:                _______________________________________ Home Phone:           _______________________________________ Office Phone:           _______________________________________ Email:            _______________________________________ Affiliation:       _______________________________________ (as it will appear on name tag) (Please make checks out to Eastern Nazarene College.) ------------------------------------------------------------------------ If Paying with Credit Card Credit Card Type:              _______________________________________ Credit Card Number:          _______________________________________ Expiration Date:              Month______  Day_____ Year______________ Signature:       _______________________________________