Name ________________________________________________________ Affiliation _________________________________________________ Street Address ______________________________________________ _____________________________________________________________ _____________________________________________________________ Country ______________________________________________ Email address ______________________________________________ Phone number ______________________________________________ Dates of attendance ________________________________________ Will you be attending the banquet on Wednesday evening? ______ Advanced Registration Fee postmarked before February 25, 2011 ( ) SIAM Member $400.00 ( ) Non-SIAM Member $445.00 ( ) Student $150.00 Regular Registration Fee postmarked on or after February 25, 2011, or paid at conference ( ) SIAM Member $445.00 ( ) Non-SIAM Member $485.00 ( ) Student $150.00 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) |