Pre-registration Form (Mandatory Fields = *)

Pre-registration deadline: Wednesday, July 5, 2006
**Registration link will be disconnected at 4PM EDT.**

All advance registration payments are to be made by credit card, check, or money order. All fees quoted are in US dollars. To take advantage of pre-registration rates, the registration form and payment must be received at the SIAM office by July 5 . The online registration form is disconnected at 4:00 PM EDT on this date.

SIAM is pleased to offer secure online processing. To ensure your registration is processed correctly, fill out this form in its entirety, being sure to include credit card number and expiration date. Click the submit button when you are finished!

You may also print and fax this completed form to SIAM at +1-215-386-7999. If paying by check (US dollars on a US bank), please make your check payable to SIAM and mail it along with this completed form to SIAM, Customer Service Department, 3600 University City Science Center, Philadelphia, PA 19104-2688, USA.

For more information on alternative payment methods, refer to How to Order SIAM Products. Any registration received without payment will not be processed.Receipts will be included in the registration packet you receive on site. 

You will receive a personalized registration confirmation via e-mail within two weeks. If you do not receive it by July 19, 2006, SIAM has not processed your registration.

Questions or problems? Contact Lillian Hunt at hunt@siam.org.

Personal Information

*First Name:
*Family Name:

*Male or Female:
(For Statistical Purposes only)

*Speaker Information:
*Organization Name:
*Organization Type:
Department:
*Address:
*City:
State:
*Zip:
*Country:
*E-mail:
Telephone:
Fax:

Student Verification

In order to qualify for the Student Rate, students must list the name, affiliation, and e-mail address of one professor who can verify your student status.

I am a
Professor Name:
Affiliation:
Professor E-mail:

Emergency Contact Information

First Name:

Last Name:

Telephone Number (Day) (Evening) )

This person’s relationship to me:

Registration Fees

All advance registration payments are to be made by credit card, check, or money order. All fees quoted are in U.S. dollars.

LS06 Conference Registration
July 31-August 4, 2006
 
SMB/SIAM Member
Non-Member
Student
Pre-registration
(on or before 07/05/06)
$290
$390
$75

If you are registering for the FULL conference, please select one of the following:

Not Attending

*PRE-REGISTERED STUDENTS AND THOSE REGISTERING ON SITE MUST SHOW A CURRENT STUDENT ID UPON CHECKING IN AT THE SIAM REGISTRATION DESK.

Student registration is available for undergraduate and graduate students ONLY.  The student rate is not available to post-doctorates.

Conference Registration Fee Includes:

Please Note: 
It is SIAM policy that all speakers must pre-register. Speakers who do not pre-register will be required to register on site at the higher rate.

If you've made any mistakes so far will reset the entire page!

Please Select the Get Together Events You Will Be Attending
To avoid wasteful preparation of food, we appreciate your help in letting us know which  functions you will attend.  All require your name badge for admission. Tickets are required for events where noted. All tickets are non-refundable after May 29.

Welcome Reception
Sunday, June 30, 2006





SIAM Business Meeting (SIAM members only)
Tuesday, August 1


SMB Business Meeting (SMB members only)
Tuesday, August 1


Subscription Event - SMB Banquet ($16 per person)
Wednesday, August 2, 2006

($16.00)

($48.00)
($64.00)

It is SIAM policy that all speakers pre-register.
Speakers who do not pre-register will be required to register on-site at the higher rate.

To confirm, please type in the TOTAL dollar amount of the fee(s) you selected.
My total fee is $ dollars.
*

It is SIAM policy that all speakers pre-register. Speakers who do not pre-register will be required to register on-site at the higher rate.

Send all SIAM correspondence to: Home Business
Update my SIAM records to reflect the above: Yes No
Are you disabled and require appropriate accommodations? Yes No

Handicap Symbol SIAM wishes to take steps to ensure that no individual with a disability is excluded, denied services, segregated or otherwise treated differently than other individuals because of the absence of auxiliary aids and services. If you need any auxiliary aids or services identified in the Americans with Disabilities Act, or assistance in registering for this conference/meeting, please contact Coley Lyons by phone: (215) 382-9800; fax: (215) 386-7999 e-mail: lyons@siam.org; or mail: Society for Industrial & Applied Mathematics, 3600 University City Science Center, Philadelphia, PA 19104-2688.

Name Badge Information:

I prefer my name and affiliation to read as follows:

Name (20 Characters):

*
Affiliation (20 characters): *

Payment Information: 

I wish to pay by:

American Express Visa *  Master Card
Name as it appears on Credit Card: *
Credit Card Number: *

Expiration Date:

*

Please submit this information to SIAM

.

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