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MMT 2000 Registration Form |
Please print out and then fill out this form. Please print or type clearly. Only one registrant per registration form.
(1) Personal Information
| Name
Dr.
Mr.
Ms. Last (Family) First (Given) Middle Initial |
| Name for Badge (if different) |
| Company / Organization Name |
| Title |
| Mailing
Address Street / PO Box City State / Province Postal / Zip |
| E-mail Address |
| Phone Number Fax Number |
(2) Registration Fee (US Dollars)
| On or Before Nov. 15 | After Nov. 15 | ||
| Full Registration | $275 | $350 | $ |
| Student / Life Member Registration | $50 | $50 | $ |
| Total Amount | $ |
(3) Fee Payment (Only by Check or Credit Card)
| Payment by Check (payable to IEEE 2000 MMT in US dollars) |
| Payment by Credit Card |
| VISA MasterCard |
| Card Number | | | | | | | | | | | | | | | | | Expiration Date / (mo/yr) |
| Cardholder Name (print) |
|
Cardholder Signature Date |
Registration will be completed only upon receipt of payment.
Please return this form:
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by
mail to Bruce Worthman IEEE Communications Society 305 East 47th St., 9th Floor New York, NY 10017, USA |