Name ________________________________________________ Affiliation _________________________________________ Street Address ______________________________________ _____________________________________________________ _____________________________________________________ Country ______________________________________ email address ______________________________________ phone number ______________________________________ Advanced Registration Fee postmarked before February 27, 2004 ( ) SIAM Member $330.00 ( ) Non-SIAM Member $370.00 ( ) Student $100.00 Regular Registration Fee postmarked on or after February 27, 2004, or paid at conference ( ) SIAM Member $370.00 ( ) Non-SIAM Member $410.00 ( ) Student $100.00 Method of Payment ( ) Check or money order enclosed Checks written to: Copper Mountain Conference Must be in U.S. funds drawn on a U.S. bank. If paying with a EuroCheque, please add $6 to your fee for bank processing. ( ) VISA or MASTERCARD only (No Amer.Expr.) Name on Card_________________________________ Card # ______________________________________ Exp. Date ___________________ Signature____________________________________ (if sending by email no signature necessary) |