Please provide the following information:

• Name: ___________________________________________

• Professional Address: _________________________________________

    ____________________________________________

• Telephone: ______________________________________________

• E-mail: ________________________________________________

Please either:

1. Print out this page, fill it in, and fax it to us at (207)-581-2323

   OR

2. Simply email the information to Ms Cathy Dunn, Department of Chemical and Biological Engineering, University of Maine
   CDunn@umche.maine.edu

   OR

3. Telephone Ms Dunn with the information at (207)-581-2277

Thank you for your cooperation.