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					                                                Midwest Thermodynamics and
                                               Statistical Mechanics Conference
                                                                 Iowa State University
                                                                     Ames, Iowa
                                                                    June 6-8, 2007                                 07-2383

Registration Information:*     Mr.     Ms.       Mrs.    Dr. Please indicate gender for housing        Female        Male
First Name                           Middle Name (Initial)                        Last Name
__________________________________________________________________                     _____________________________
Institution                                Dept./Subunit                                      Job Title
__________________________________________________________________                     _____________________________
Email                                                                                         Day Phone
__________________________________________________________________                     _____________________________
Mailing Address Line 1                                                                        Evening Phone
____________________________________________________________________                   ______________________________
Mailing Address Line 2                                                                        Fax Number
City                                         State           Zip Code

Fees without Accommodations                                                                   It’s easy to Register!
(includes continental breakfasts, coffee breaks, and banquet)                                 Online------
   Graduate Student/Postdoc                                                       $65.00
   Faculty Member                                                                $115.00      Mail------
Fees including Accommodations                                                                 Iowa State University
(includes lodging, continental breakfasts, coffee breaks, and banquet)                        Continuing and Distance
   Graduate Student/Postdoc (single room – limited availability)       $125.00                 Education
   Graduate Student/Postdoc (double room)                              $125.00                102 Scheman Building
    Preferred Roommate’s name if known, otherwise roommate of                                 Ames, IA 50011
    same gender will be assigned ______________________________
   Faculty Member (single dorm room)                                   $175.00
                                                                                              (515) 294-6223
                                                                                                 Please contact me, I have
I will attend the Thursday, June 7 Banquet (included in fee)       Yes      No
                                                                                              special dietary needs and/or
                                                                                              need accommodations for a
Method of Payment                                                                             disability.
  Check (Payable to Iowa State University)
                                                                                              * Iowa State University requests
  Credit Card                Visa              MasterCard                Discover             this information to preregister you
                                                                                              in a conference. No one outside the
Card Number ______________________________________                 Exp. Date ____ /____       university, with the exception of
                                                                                              participants in this conference, is
Cardholder Name ___________________________ Signature ___________________                     routinely provided this information.
                                                                                              If you fail to provide the required
  Purchase Order (Please indicate billing address below, if different from                    information, we cannot promise
above)                                                                                        accurate registration. (Reference:
                                                                                              Iowa Code, Chapter 22.11; Iowa Fair
       PO Number             ___________________________________________                      Information Practices Act)
        Send Invoice to:     Name ___________________________________________
                                                                                                    Office Use Only
        Billing Address             ___________________________________________
        Telephone / Fax             _____________________ /____________________
(Only one registration per form - Duplicate for additional registrations)

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