Registration Form RAID99 3057JMW

Please return this form by fax (765) 494-0567 or regular mail to:

Business Office Conferences Note: Registration will open on July 15, 1999.

Purdue University

1586 Stewart Center, Room 110

West Lafayette, IN 4797-1586

Registration will close on August 21, 1999. Late registration will continue until September 3, 1999, but only on a space-available basis, and will include a penalty of $US50 (in addition to the fees below). After September 3, 1999, only registration at the door will be available, space permitting.

Name ________________________________________ Institution___________________________________

(As you would like it to appear on your name badge)

Address __________________________________________________________________________________

City____________________________ State__________Zip________________Country_______________

Phone__________________Fax___________________Electronic Mail______________________________

_____Check here to EXCLUDE your name and address from the list of attendees.

_____I will require auxillary aids or services due to a disability. Please contact me at the above address.

_____I would like vegetarian meals.

ConferenceRegistrationFee			Aug 21 or earlier	After Aug 21		Full Time Students may apply for a waiver of registration fees by contacting Eugene H. Spafford, Director, CERIAS. Applications for stipends to reduce travel cost may be made to Deb Frincke, Program Chair. Only a limited number of applications may be considered and should include a short description of your research and be supported by your faculty advisor. We cannot promise that applications received after August 21 will be considered.
_____	Full-Time Student		$150	$200
_____	Regular Registration		$250	$300
	Total payment		$_________	$_________

Payment Method

All payments must be made in $US. Remittance should be free of any bank charge to the organizers.

_____Enclosed is my check made payable to Purdue University

_____I will be using a purchase order to pay my fees.P.O.#______________________________________

If using a P.O. for more than one registrant, please complete a registration form for each participant and return together.

_____Credit Card (Register by Fax or Regular Mail)

Master Card_____Visa_____Discover_____

Card Number__________________________________Exp. date ___________________________

Cardholder'sname_______________________________Date ______________________________

Cardholder's signature ______________________________________________

Get the RAID Travel and Accommodations Info