2004 IEEE Information Theory Workshop by WesleyL


									            2004 IEEE Information Theory Workshop
              San Antonio, Texas October 24-29, 2004

                            Workshop Registration Form
Title:_______ Last Name:______________________________________________
First Name: _________________________________________________________
Institution: _________________________________________________________
Mailing Address: _____________________________________________________
Country: ________________________ Post/Zip Code: ______________________
Email address: ______________________________________________________
Fax: ____________________________ Phone: ____________________________
Dietary restrictions/preferences _________________________________________

Registration: (Early registration is through September 3, 2004)
IEEE members: Member #______________ Early Registration                             $375.00 USD
Non-IEEE members: Early Registration                                                $425.00 USD
IEEE members: Member #______________ Late/On-Site Registration                      $425.00 USD
Non-IEEE members: Late/On-Site Registration                                         $475.00 USD
Student Registration:                                                               $75.00 USD

                                      Subtotal Conference Registration Fee $_________

Student registration includes sessions, morning and afternoon breaks and welcome
reception. Non-student registration includes, in addition to the above, proceedings (CD-
ROM) and banquet. Guests/Spouses will be required to purchase a ticket to attend
the banquet.

Please reserve ________ extra banquet tickets @ $70.00 USD per ticket.
Dietary restrictions/preferences _______________________________________________

                                                      Subtotal Banquet Tickets $ ________
Extra CD-ROM’s ____ @ $20.00 USD per CD-ROM:                 Subtotal CD-ROM’s $ ________

                                                             Grand Total USD: $ _________

All fees quoted are in USD and all payments should be made in USD. Please make
           all payments to the 2004 IEEE Information Theory Workshop.
 NOTE: Every registrant must fax or mail the registration form regardless of payment option chosen.

       Check enclosed in USD. Check # _______________

       Payment by bank/wire transfer: Routing/ABA # 314970664; Account# 3803088305
       Guaranty Bank, 717 University Drive, College Station, TX 77840.
       Ph: 1-979-846-7774 or 1-800-288-8822

       Credit Card Payment: I hereby authorize the organizing committee of 2004 IEEE ITW to
       charge my credit card

                Visa            Mastercard           American Express

Name on Card (please print): _________________________________________________
Number on Card:_____________________________ Exp. Date:_____________________
Signature:_________________________________________ Date: __________________
   Please return to: 2004 IEEE ITW, Attn: Sonny Matous, Electrical Engineering Dept., Texas A&M
                  University, College Station, TX 77843-3128. Fax: 979-862-4630
                       Phone: 979-862-8657 E-mail: itw2004@ee.tamu.edu

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