1995 SIAM Annual Meeting
Preregistration Form

Note: If you use Fill-in Forms to register, SIAM will send you confirmation of your electronic registration within 10 working days. If you do not receive confirmation, please contact SIAM Customer Service at 215-382-9800 or 800-447-SIAM (toll free, USA only).

There is a "Submit Registration" button at the bottom of this fill-in form. If you don't see the button, or if any of the check boxes or fill-in blanks do not appear correctly, your Web browsing software is not capable of handling this form. If that is the case, you should register by one of the methods listed in the Registration Information.

Preregistration Form
Preregistration Deadline: Monday, October 9, 1995

No refunds will be issued after October 20, 1995 


                                    SIAM Member     Non-Member      Student
*Short Course on Wavelets		
    Preregistration (before Oct 9)  $130            $145            $60
    Registration (after Oct 9)      $145            $160            $75

*Short Course on Electronic Circuits
    Preregistration (before Oct 9)  $130            $145            $60
    Registration (after Oct 9)      $145            $160            $75

Meeting
    Preregistration (before Oct 9)  $150            $180            $30
    Registration (after Oct 9)      $190            $230            $30

BBQ Dinner                          $36             $36             $36

*Registration fee for either short course includes course notes.

Option and Rate Selection:

I fall into this category: SIAM Member Non-member Student

I would like to register for:

Note: Multiple boxes may be checked. However, the short courses are simultaneously held on Sunday, October 22, 1995. Therefore, you cannot register for both short courses.

Conference
Short Course on Wavelets
Short Course on Electronic Circuits
BBQ Dinner

Based on the registration fees chart above and the options I chose, my registration fee should be dollars.

Name, Address, and Phone Information

Name:

Organization:

Department:

Business Address:

City: State: Zip:

Telephone:

E-mail:

Fax:

Home Address:

City: State: Zip:

Please send all SIAM correspondence to the following address: Home Business

Please update my SIAM records to reflect the above: Yes No

Are you a disabled participant that requires appropriate accommodations? Yes No

Name Badge Information:

NAME BADGE - I prefer my name and affliation to read as follows:

Name (20 characters): Affliation (20 characters):

Payment Information:

I wish to pay by: AMEX VISA Master Card

Credit Card Number: Expiration Date:

Now, to submit your registration form to SIAM, press this button:

8/18/95