Computational Differentiation
Preregistration Form

February 12-15, 1996
La Fonda Hotel
Santa Fe, New Mexico

There is a "Submit Registration" button at the bottom of this fill-in form. If you don't see the button, or if any of the check boxes or fill-in blanks do not appear correctly, your Web browsing software is not capable of handling this form. If that is the case, you should register by one of the methods listed in Registration Information.

SIAM will send you confirmation of your electronic registration within 10 working days. If you do not receive confirmation, please contact the SIAM Customer Service Department at (215) 382-9800 or 800-447-SIAM (toll free, USA only).

Preregistration deadline: Monday, January 29, 1996

Registration Fees
ACM/SIAM Member Non-Member Student
Preregistration: (Before 1/29/96) $150 $190 $50
Registration: (After 1/29/96) $190 $230 $50
Special Events
Indian Ruins Tour $40 $40 $40
Southwest Mex. Dinner $23 $23 $23

No refunds will be issued after Sunday, February 11, 1996.

Option and Rate Selection

I fall into this category: ACM/SIAM Member Non-member Student

I would like to register for the following Special Events: Indian Ruins Tour Southwest Mexican Dinner

Based on the registration fees chart above and the options I chose, my registration fee should be dollars.

Name, Address, and Phone Information

Name:
Organization:
Department:
Business Address:
City: State: Zip:
Telephone: E-mail:
Fax:
Home Address:
City: State: Zip:

Please send all SIAM correspondence to the following address:
Home Business

Please update my SIAM records to reflect the above:
Yes No

Are you a disabled participant that requires appropriate accommodations?
Yes No

Name Badge Information:

NAME BADGE - I prefer my name and affliation to read as follows:
Name (20 characters): Affliation (20 characters):

Payment Information:

I wish to pay by: AMEX VISA Master Card
Credit Card Number: Expiration Date:

Preregistration Form and payment must be received at the SIAM office by January 29, 1996.

Now, to submit your registration form to SIAM, press this button:


Back to Registration Information

MEM, 1/3/96