Advance Registration Form - MP Associates, Inc.

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.