Advance Registration Form - MP Associates, Inc.

Advance Registration FormConference Management:MP Associates, Inc.1721 Boxelder St., Ste. 107Louisville, CO 80027 USAPhone: 303-530-4562Fax: 303-530-4334Intl: +1-303-530-4562, Fax: +1-303-530-4334www.mpassociates.com1313 th International Forum on Embedded MPSoC and MulticoreJuly 15 -19, 2013, Otsu, JapanConference Registration will include: conference materials, lunch for five days and dinner for four evenings including the social dinner.Two-day registration will include: conference materials, lunch for the two days attending the conference and dinner for the first evening.Additional person includes: Dinner for four evenings and all social activities.1PRINT ATTENDEE INFORMATIONFirst Name__________________________________ Last Name_______________________________________ Company_______________________________________Title__________________________________________________ Address_________________________________________________________________________City______________________________________________________State/Province/Region_____________________________________________________Zip/Postal code________________________________________________________ Country_____________________________________________________Phone_____________________________________ Fax___________________________________Email___________________________________________2MEMBERSHIP STATUSI certify that I am an EDAA member._____________________________________________________ member#____________________signatureI certify that I am an IEEE member._______________________________________________________ member#____________________signatureI certify that I am a full time student._______________________________________ member#______________student#____________signatureThis is for individualmemberships only.This does notapply to companymemberships.Membership # must be included at time of submission to receive the membership rate. No refunds will be made for change in membership status.Send full payment in U.S. dollars with this form. Use a check drawn on a US bank or a major credit card. For payments from non-U.S. banks the attendee will becharged a collection fee of US $45.00. Purchase orders are not accepted. Use your credit card if registering by fax.REFUNDS: Requests for refunds received before May 17, 2013 will be subjected to a $50 processing fee. No refunds will be made for cancellations received afterMay 17, 2013 and all registration fees will be forfeited. Register early to avoid disappointment.3REGISTRATION OPTIONS (required)4PAYMENT INFORMATION (required)Before May 17, 2013 After May 17, 2013___1) Conference $1.300 US $1.600 US___2) Member EDAA/IEEE $1.100 US $1.300 US___3) Student $ 760 US $1.100 US___4) Speaker $ 760 US $1.100 US___5) 2 Days Only $ 760 US $1.100 USPlease circle one: Mon/Tue Tue/Wed Wed/Thur Thur/Fri___6) Additional Person$ 360 US___7) Additional Social Dinner $ 60 USCredit Cards: _____ VISA_____ MASTERCARDCard #: __________________________________________Security Code: __________Name: _____________________________________________Exp. Date:______________Please print name as it appears on the credit cardSignature: ______________________ _______________________I agree to pay the total amount according to the card issuer agreement.For assistance with wire transfers, please contact: Nannette@mpassociates.comSocial DinnerRegistration FeesTOTAL COST$________________$________________$________________Make U.S. checks payable to MPSoC.

On-Site Registration FormConference Management:MP Associates, Inc.1721 Boxelder St., Ste. 107Louisville, CO 80027 USAPhone: 303-530-4562Fax: 303-530-4334Intl: +1-303-530-4562, Fax: +1-303-530-4334www.mpassociates.com1313 th International Forum on Embedded MPSoC and MulticoreJuly 15 -19, 2013, Otsu, JapanConference Registration will include: conference materials, lunch for five days and dinner for four evenings including the social dinner.Two-day registration will include: conference materials, lunch for the two days attending the conference and dinner for the first evening.Additional person includes: Dinner for four evenings and all social activities.1PRINT ATTENDEE INFORMATIONFirst Name__________________________________ Last Name_______________________________________ Company_______________________________________Title__________________________________________________ Address_________________________________________________________________________City______________________________________________________State/Province/Region_____________________________________________________Zip/Postal code________________________________________________________ Country_____________________________________________________Phone_____________________________________ Fax___________________________________Email___________________________________________2MEMBERSHIP STATUSI certify that I am an EDAA member._____________________________________________________ member#____________________signatureI certify that I am an IEEE member._______________________________________________________ member#____________________signatureI certify that I am a full time student._______________________________________ member#______________student#____________signatureThis is for individualmemberships only.This does notapply to companymemberships.Membership # must be included at time of submission to receive the membership rate. No refunds will be made for change in membership status.3REGISTRATION OPTIONS (required)4PAYMENT INFORMATION (required)___1) Conference$1.600 US___2) Member EDAA/IEEE$1.300 US___3) Student$1.100 US___4) Speaker$1.100 US___5) 2 Days Only$1.100 USPlease circle one: Mon/Tue Tue/Wed Wed/Thur Thur/Fri___6) Additional Person $ 360 US___7) Additional Social Dinner $ 60 USCredit Cards: _____ VISA_____ MASTERCARDCard #: __________________________________________Security Code: __________Name: _____________________________________________Exp. Date:______________Please print name as it appears on the credit cardSignature: ______________________ _______________________I agree to pay the total amount according to the card issuer agreement.Social DinnerRegistration FeesTOTAL COST$________________$________________$________________Make U.S. checks payable to MPSoC.