Name ________________________________________________________ Affiliation _________________________________________________ Street Address ______________________________________________ _____________________________________________________________ _____________________________________________________________ Country ______________________________________________ Email address ______________________________________________ Phone number ______________________________________________ Dates of attendance ________________________________________ Will you be attending the banquet on Thursday evening? ______ Advanced Registration Fee postmarked before March 3, 2010 ( ) SIAM Member $395.00 ( ) Non-SIAM Member $435.00 ( ) Student $160.00 Regular Registration Fee postmarked on or after March 3, 2010, or paid at conference ( ) SIAM Member $435.00 ( ) Non-SIAM Member $475.00 ( ) Student $160.00 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) |