REGISTRATION FORM

Copper Mountain Conference on
Copper Mountain, Colorado, ,

Please use the address you want to appear on the attendee list.

Name ________________________________________________
 
Affiliation _________________________________________
 
Street Address ______________________________________
 
_____________________________________________________
 
_____________________________________________________
 
Country        ______________________________________
 
email address  ______________________________________
 
phone number   ______________________________________
 
Advanced Registration Fee
postmarked before , 
	(   ) SIAM Member $.00
	(   ) Non-SIAM Member $.00
	(   ) Student $.00

Regular Registration Fee
postmarked on or after , , or paid at conference
	(   ) SIAM Member $.00
	(   ) Non-SIAM Member $.00
	(   ) Student $.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)