Please print this form and FAX or send the form with your payment to the address at the bottom of this form.
First Name:_______________________ Last Name:___________________________
Affiliation:_____________________________________________________________
Address:______________________________________________________________
City:_____________________________ State/Province:________________________
Country:_____________________________ Zip Code:_________________________
E-mail:______________________________ Phone: ___________________________
Fax:________________________________ IEEE member number:_______________
Conference registration fees: (Please check all that apply)
| By May 25, 2003 | After May 25, 2003 | |
| IEEE member | $400______________ | $480______________ |
| Non-IEEE member | $500______________ | $600______________ |
| Full-time student | $300______________ | $360______________ |
| Tutorials (TBA) | $50______________ | $60______________ |
Extra Banquet Tickets _____ @ $50.00 ea = $ ___________ Vegetarian?_____
Add up your above charges, and enter the total due below, payable in US dollars. Payment can be made with Visa, MasterCard, Amex, Check (payable to IEEE CEC03) or Money Order. Please note that your credit card payment will be handled by "IEEE" for CEC03.
Total Due: US $ ________________
Payment Method: Check_____ Visa______ MasterCard______ American Express_______
Card Number: _____________________________ Exp Date (MM/YY): ________________
Name on card: ____________________________ Signature: ___________________________
FAX (or mail your form with check) to the following address:
Prof. Kwei-Jay Lin
Dept EECS, Univ. California, Irvine
Irvine, CA 92697-2625
USA
fax: +1-949-824-2321
klin@uci.edu