ICNP 2001 short registration form


Name:		________________________________________________________
		(First)		(Middle)			(Last)

Affiliation:	________________________________________________________

Address:	________________________________________________________

City:		______________________ 	State: _________________________

Zip Code: 	______________________	Country: _______________________

Phone:		______________________ 	Fax: ___________________________

Email:		________________________________________________________


Are you a Member of IEEE/Computer Society? Yes #_____________
 
Conference Registration EDP# 012Q91:
Advance Reg. (by October 10, 2001):	Late/On-Site Reg.:
IEEE Member	$500.00	__________	IEEE Member	$600.00	__________
Non-Member	$625.00	__________	Non-Member	$725.00	__________
Student		$150.00	__________	Student		$175.00	__________
Extra Reception	$50.00	__________	Extra Reception $50.00	__________
Total Amount Due:	__________	Total Amount Due:	__________

Tutorials EDP#012Q92:
Advance Reg. (by October 10, 2001):	Late/On-Site Reg.:	
IEEE Member	$250.00	__________	IEEE Member	$300.00	__________
Non-Member	$320.00	__________	Non-Member	$375.00	__________
Student		$200.00	__________	Student		$250.00	__________
Total Amount Due:	__________	Total Amount Due:	__________

I will be attending the _____ FULL-DAY Tutorial, or ______ the two 
HALF-DAY Tutorials (please check at most one).

Food Restrictions: 	Vegetarian/Diet	(   ) ____________

Amount to be charged: 	_____________ 

1.  Credit Card # __________________________________ Expiration __________
		   (Visa and Master Card Only)
	Signature: (Required for Credit Card)_____________________________
	Name: ____________________________________________________________

2.  Check or Money Order:	Payable to UC Regents (In USD)

Address for Mailing:		
Les J. Cromwell, Manager, Conference & Instructional Support Services
Attention:  ICNP Conference 2001
University of California, Riverside
1200 University Avenue
Riverside, CA 92507-4596
Email:	Lcromwell@ucx.ucr.edu
Fax: (909) 787-7273	Telephone: (909) 787-4105 Ext. 1075