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:
|
by
mail to Bruce Worthman IEEE Communications Society 305 East 47th St., 9th Floor New York, NY 10017, USA |