2007 Symposium Brochure 3.pub - Ultrasonic Industry Association

1
2
UIA 2007 SYMPOSIUM REGISTRATION FORM - 19 - 21 MARCH 2007
P LEASE TYPE OR PRINT
First name
Last name
Nickname for badge
Position/Title
Employer
City, State/Prov, Country
F OR MAILING PURPOSES, I PREFER MY [ ]HOME ADDRESS [ ] WORK ADDRESS AS FOLLOWS:
Address
City, ST, Zip, Country
To help us contact you during the day, please note your preferred numbers:
Telephone
Fax
E-mail
3
[ ] Please DO NOT include my name and mailing information in any published lists
[ ] S PECIAL ACCOMMODATIONS - If you require special accommodations for a disability to attend this meeting, please
check this box. We will contact you to discuss this further.
P LEASE REGISTER ME IN THE FOLLOWING MANNER:
Registration Type B Y 15 Dec A FTER 15 DEC Amount Due
Full Conference - Member $635 $715 $
Full Conference – Non member* $790 $865 $
Daily Rate – Member
Mon Tues Wed
Daily Rate – Non member
Mon Tues Wed
$300 $350 $
$375 $425 $
*Full conference registration for nonmembers includes individual membership for the balance of 2007
Tuesday Evening Special Event $95 # of tickets _______ $
Speakers and Accepted Poster Presenters
Daily
$250
Mon Tues Wed
Full Conference
$550 $
4
5
Student
$145
Mon Tues Wed
$495 $
METHOD OF PAYMENT FIN for voucher use only: 13-6130371
[ ] Payment enclosed. Please make checks payable to: UIA Payable in US Funds, please
[ ] Please charge my credit card: [ ] Master Card [ ] Visa You may register online after 10 November
Card Number: EXP /
Person’s name on card
Signature of
that person
Business Card Personal Card
C ORRESPONDENCE INFORMATION - REGISTER ONLINE AT WWW. ULTRASONICS. ORG
Mail registration form and all payments to:
UIA, P O Box 2307
Dayton, OH 45401-2307
Fax registration form to:
+1.937.586.3699
Address for express mail only:
11 West Monument Ave, Ste
510
For further information call:
+1.937.586.3725