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 January 29, 2016 ( ) SIAM Member $425.00 ( ) Non-SIAM Member $475.00 ( ) Student $175.00 Regular Registration Fee postmarked on or after January 29, 2016, or paid at conference ( ) SIAM Member $475.00 ( ) Non-SIAM 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) |