REGISTRATION FORM

Copper Mountain Conference on Multigrid Methods
Copper Mountain, Colorado, March 22 - March 27, 2015

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

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 March 2, 2015
	(   ) SIAM or AWM Member $425.00
	(   ) Non-SIAM and non-AWM Member $475.00
	(   ) Student $175.00

Regular Registration Fee
postmarked on or after March 2, 2015, or paid at conference
	(   ) SIAM or AWM Member $475.00
	(   ) Non-SIAM and non-AWM Member $520.00
	(   ) Student $175.00
 

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)