Last Name:_______________________ First Name:__________________ Middle Initial:_____
Street Address:__________________________________________________________________________
City:_______________________________________ State:________________ Zip:__________________
Email:_______________________ Telephone (Day):__________________ (Evening):________________
Institutional Affiliation:___________________________________________________________________
_______ I plan to attend the Social Hour on Friday evening
_______ I plan to attend the Social Hour on Saturday evening
Please return this form to:
Department of History Activism Conference Mail Code 2527 611 Fayerweather Hall Columbia University New York, NY 10027 Questions? Send them to [email protected]