speaker 4th ASS S lecturer Speaker Registration Form Last Name by xiaopangnv

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									4th ASS & S lecturer/Speaker Registration Form

Last Name
First Name
If Chinese, Chinese Name (中文姓名)

Passport No. (ID number, if Taiwanese)

Gender :
(Male / Female)
Birthday :(YYYY-MM-DD)
Nationality
Affiliation/ Institute/ University
Title (Student/ Engineer/ Researcher/
Professer etc.)
Tel
Fax
Cellular Phone, if applicable
E-mail
Address/ Country
Intend to give a lecture? (Y/N)

                                                                                                                III - Particle Acceleration
If yes for line 17, choose a session          I - Laser Science (Y/N)              II- Plasma Physics (Y/N)
                                                                                                                (Y/N)
Intend to give a conference talk? (Y/N)
If yes for line 19, provide a title of the talk.
Arrival Date, Time
Arrival Airline, Flight Number
Number of Companion?
Airport pickup? (Y/N)
Departure Date, Time
Departure Airline, Flight Number
Hotel to airport transportation? (Y/N)
Date of ASS hotel check in, if different
from line 21
Date of ASS hotel check out, if different
from line 25
Vegetarian diet? (Y/N)
Bring a laptop computer?(Y/N)
Lecture-note media preference: ___ CD, ____ Hardcopy (3-hole binder), ___ Electronic file download
                                              1. _____ I am willing to pay a
                                                                                                                3. _____ I must apply a
                                              voluntary registration fee of      2. _____ I prefer not to
Voluntary Registration Fee (Check one)                                                                          financial support to defray
                                              USD$________ to help others attend pay any registration fee.
                                                                                                                my air travel to this event
                                              this event.
Special request




Remarks
* Passport and Birthday infomation are for domestic insurance purpose
*Those who intend to a lecture in the school or to give a oral presentation in the symposium will be recommended to the International
Curriculum and Program Committee for a decision on granting invitation.
* Lectures and Speakers will be arranged to rooms with single occupacy.
                         V - Laser-plasma
IV - Radiation Physics
                         Acceleration and
(Y/N)
                         Simulationv(Y/N)

								
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