Contact Information

Name:
Institutional Affiliation:
Address:
City: State/Province:
Postal/Zip Code: Country:
Phone: Fax: E-Mail:

Registration Fee*

Regular (US$150) or Student (US$90)
Registration received on or after April 16, 2006 will be US$160 (US$100 for students).
Registration includes dinner on Friday and refreshments between sessions.

Method of Payment

I have enclosed a check or money order in US currency payable to Purdue University
Please charge my credit card: Visa, MasterCard, or Discover
Account Number Expiration

Authorized Signature ______________________________________________

Total Enclosed: US$150 (Early Registration, Regular) US$90 (Early Registration, Student) US$160 (Late Registration, Regular) US$100 (Late Registration, Student)

Print out the completed form and send it to:

Continuing Education Business Office
Purdue University
1586 Stewart Center, Room 110
West Lafayette, IN 47907-1586 USA

Fax: +1-765-494-0567