PerCom 2005 - Conference Registration Form

s PerCom 2005 - Conference Registration Form

Orlando

PerCom 2003

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General Registration Information

Discounted registration fees are available for members of the IEEE. Discounts are also available for students.
Early registration: The cut-off date for early registrations is 11:59 pm PST on February 15th, 2005. Our servers will be automatically updated for the appropriate early/late charges.
Refund policy: There is a $35 service charge for processing refunds. A letter or email requesting the refund should state the pre-registrant's name and to whom the check should be made payable. Requests for registration refunds must be received before February 18th, 2005. No refunds will be issued after February 18th, 2005. There is no refund for registration fees on author registrations. Author registrations may be transfered to a co-author in case the original registree cannot show.
Author registration deadline is December 22, 2004. Each accepted paper has to have one author registered as a full (non-student) technical session attendee. For authors who have several accepted papers, one of the papers has to have a full (non-student) registration, while all other papers of the author may have a student (co-author) registration.
Banquet policies: Student registration fees do not include tickets to the banquet. If you register as a student and wish to attend the banquet make sure you purchase an additional ticket. Workshop only registrations do not include tickets to the banquet.

Conference Registration Form

Name and Address

*Prefix	Prof. Dr. Mr. Mrs. Ms. Miss
*First	M.I. *Last
Title
Company/Affiliation
Mail-Stop / Dept.
*Street Address
*City
State
*Country
*ZIP or Postal Code
*Phone	Fax
*E-Mail
*Re-type E-Mail

Items marked with an asterisk (*) MUST BE FILLED OUT before your registration information can be processed. Please make sure that your email addresses match and are correct. Your email address will be used to confirm your registration as well as to exchange any further correspondence with you.

IEEE Membership

Please mark this box if you are a member of the IEEE.
For current memberships, please enter your IEEE member number:

If you are not a member, become a member of the IEEE now and receive the member conference registration rate.

Author Status Please mark this box if you are an author presenting a paper (responsible author). Please enter paper number: Please enter the number of pages over the page limits: @ $150 each. Please note that you have to have the approval of the Program Committee Chairs in order to purchase extra pages. Student Status Please mark this box if you are a full-time student. (No banquet ticket included.) Please mark this box instead of the one above if you are a full-time student and an author, and are requesting student author registration based on "more than one accepted paper from a group with the same author" basis. (No banquet ticket included.) Technical Sessions Technical Session Fees Early Registration Late Registration Member Non-Member Full-time Student Member Non-Member Full-time Student $550 $675 $150 $625 $775 $200 Please mark this box to register for the technical sessions and all workshops (March 14-17).

Workshop Only Registration

Workshop Only Fees	Early Registration			Late Registration
	Member	Non-Member	Full-time Student	Member	Non-Member	Full-time Student
	$225	$300	$75	$275	$350	$120

Please mark this box if you would like to register for only the workshops on Sunday (March 14th). (No banquet ticket.)

Banquet Tickets

One ticket is included in a (non-student) conference (technical sessions) registration fee. Purchase additional tickets below.: Number of additional tickets: @ $50 each.; Banquet Date: TBA

Special Needs

Please mark this box if you have vegeterian preferences

Please mark this box if you have any other special needs. Please enter these needs below:

Payment Information

Grand Total:

Method of Payment:
		Visa on-line
		MasterCard on-line
		Visa off-line (print and fax/mail with cc information)
		MasterCard off-line (print and fax/mail with cc information)
		Print and Mail with Check/Money Order. (Please click on "Process Form" even if you have selected this option and print the follow-up page.)
		On Site payment. (Please click on "Process Form" even if you have selected this option and print the follow-up page.)

Card-holder's Name:

Expiration Year: Month:

Card Number (In case of on-line payment only):

After you have filled out the form, please click on the "Process Form" button above. Please do so even if you have elected to mail/fax your information to us, since you will need to print the follow-up page.