MPKC 2003 registration form

MPKC 2003 registration

My last name:              _____________________________________________

My first name:             _____________________________________________

My title (Prof./Dr./etc.): _____________________________________________

I am a student:                                          [ ] Y     [ ] N

My affiliation:   ______________________________________________________

My email address: ______________________________________________________

Please mail my receipt to this address:

                  ______________________________________________________

                  ______________________________________________________

                  ______________________________________________________

                  ______________________________________________________

Other participants should contact me
about possibly sharing a hotel room:   [ ] Y male   [ ] Y female   [ ] N

Other messages to publish:

                  ______________________________________________________

                  ______________________________________________________

My attendance is a secret,
so please hide all of this information:                  [ ] Y     [ ] N

I would like a temporary UIC computer account:           [ ] Y     [ ] N

(If Y:) Please use the following account name: mpkc2003- _______________

(If Y:) Please use the following password:               _______________

To register, send this form and your registration check to

Terri Hovde
University of Illinois
102 CSL
1308 W. Main Street
Urbana, IL 61801
USA

Registration fees:

$40 for students, $80 for others, if postmarked on or before 17 October 2003.
$80 for students, $160 for others, if postmarked after 17 October 2003.

Registration checks must be drawn on a United States bank in United States currency payable to University of Illinois.