Pre-registration Form (Mandatory Fields = *)

Pre-registration deadline: Monday, May 3, 2004
**Registration link will be disconnected at 4PM EDT.**

SIAM is pleased to offer secure ordering. If you are uncomfortable sending credit card information over the Internet via a secure socket connection, please print this order form, fill it out, and fax it to SIAM at (215) 386-7999. If paying by check, please make your check payable to SIAM and mail it with this filled-in form to SIAM, 3600 University City Science Center, Philadelphia, PA 19104-2688. For more information on alternative payment methods, please refer to How to Order SIAM Products.

AN E-MAIL CONFIRMATION WILL BE SENT TO YOU WITHIN 10-15 WORKING DAYS. If you do not receive it, SIAM has not processed your registration. Please contact [email protected] if you do not receive an e-mail confirmation by April 17, 2004. Your printed receipt will be included in your registration packet on-site.

To ensure that your registration is processed correctly, please fill in the following form as accurately as possible. Make sure you include your credit card number and expiration date. Registrations received without payment will not be processed. Remember to push the submit button when you're finished! A pop-up message should appear saying "Thank you for filling in the form. Your response has been received by our server. Thank you for using the SIAM Web Server." This is not your registration confirmation. If you do not see this pop-up message, please contact [email protected] for assistance.

All advance registration payments are to be made by credit card, check, or money order. All fees quoted are in U.S. dollars. To take advantage of pre-registration rates, both the Registration Form and payment must be received at the SIAM office by Monday, May 3. The on-line registration form is disconnected at 4 PM EDT.

Personal Information

*First Name:
*Last 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:

Please select only one of the registration fees below.

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

MS04 Conference Registration

Conference Registration Fees
SIAM Member
Non-Member
Student
Pre-registration (on or before 5/03/04)
*$295
$395
$85

On-Site Registration (After 5/03/04)

$395
$495
$85

*NOTE: Minisymposia Speakers and Organizer pay the SIAM Member rate.
Conference Registration (Please select an option)

* BOTH PRE-REGISTERED AND STUDENTS REGISTERING ON-SITE MUST BE PREPARED TO SHOW A
CURRENT STUDENT ID UPON CHECKING IN AT 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:

Welcome Reception
Admission to poster sessions
Two coffee breaks daily
Room set-ups and audio-visual equipment
Admission to all technical sessions
Internet Café

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 meal functions you will attend. All require your name badge for admission.
Tickets are required for events where noted. All tickets are non-refundable after Monday, May 3.

Please indicate if you will be bringing any guests.

Welcome Reception and Poster Session
Saturday, May 22





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: [email protected]; 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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2/9/04