Registration  Form for Random-Approx '99 Conference

EARLY REGISTRATION DEADLINE: June 30, 1999
 

 Family Name:
                 ____________________________
 First Name:
                 ____________________________
 Organization:
                 ____________________________
 Department:
                 ____________________________
 Organization Address:
                 ____________________________

                 ____________________________
 City:
                 ____________________________
 State:
                 ____________________________
 Zip Code:
                 ____________________________
 Country:
                 ____________________________
 Telephone:
                 ____________________________
 Fax:
                 ____________________________
 Email Address:
                 ____________________________
 
 
 

PAYMENT INFORMATION

We are unable to accept International Postal Money Orders. Please enclose check in U.S. dollars
 or International Money Order payable to:  Random Conference and
send it to
Jose Rolim
C.U.I.
24 rue General Dufour
1204  Geneva
Switzerland

We accept payment by mail or fax using either Visa, Mastercard,  or American Express. Please complete the
following information when using a credit card:

 Type of credit card:
                           ____________________________
 Credit card number:
                           ____________________________
 Expiration date:
                           ____________________________
 Print name as shown on credit card:
                           ____________________________
 

 Signature:
                           ____________________________
 

REGISTRATION FEES
(includes entrance to all sessions, the minisymposium,  a copy of the proceedings, the banquet on Tuesday evening, coffee breaks and other conference costs):

 $200.00
       Early registration received before June 30, 1999
                                       $________________
 $170.00
       Student registration received before June 30, 1999
                                       $________________
 $280.00
       Regular registration
                                       $________________
 $250.00
       Student registration received after July 15, 1998
                                       $________________

       Subtotal Registration Fees
                                       $________________
 
 
 

Please fax or e-mail to:

Jose Rolim
Random-conference
email: rolim@cui.unige.ch
fax: 1 - 213 - 740 9127