RTSS 2005 REGISTRATION

You may register by filling in this on-line registration form and submitting it, or emailing the required information to lindabuss@mac.com, faxing this information, or sending it by paper mail. As with any web-based transaction, there is some risk involved with sending your information over the Internet such as possible unauthorized interception and subsequent unauthorized use of your credit card data. Steps have been taken to provide as secure an environment as possible for transmitting and storing your information, but we cannot guarantee that this system is immune to all security breaches. Your credit card data may be compromized. If you have any concern about this, please directly mail or fax the registration information below to Linda Buss via the following contact information:

Linda Buss

E3774 - 550th Ave.

Menomonie, WI 54751

Fax: 715-232-6244

Phone: 715-235-0487

Email: lindabuss@mac.com

Please be sure to reserve a room before the hotel reservation cut-off date: Sunday, 13 November, 2005 at 5:00 p.m. Eastern Standard Time.

1. Personal Information

First Name:

  Last Name:

Affiliation:

Street Address:

City:

  State:     Zip Code:

Country:

Phone:

  Fax:

Email:

IEEE Membership Number:

If you are registering at the conference as an IEEE Member,

2. Fees (in US dollars):

Workshop/Tutorial Fees (covers all workshops):

Category

Nov 15, 2005 or Before

After Nov 15, 2005

Workshop/Tutorial
(IEEE members)
$200

$250

Workshop/Tutorial
(non-members)

$250

$310

Workshop/Tutorial
(student members)
$150

$200

Workshop/Tutorial
(student non-members)

$185

$250

Symposium Fees:

Category

Nov 15, 2005 or Before

After Nov 15, 2005

IEEE Members

$600

$750

Non-Members

$750

$900

Student Members
$400

$500

Student Non-Members

$500

$625

Workshop Fee: $

Symposium Fee: $

Extra Banquet Tickets ($100 each): $

Extra Page Charges ($200 per page): $

Total Due: $

3. Credit Card Information

Credit Card:

Credit Card Number:

Name EXACTLY as it appears on credit card:

Credit Card Expiration Date:

(MM/YY)

Total Charges Authorized:

4. If you are registered as a student, please provide the following:

Advisor name:

Advisor email address:

5. Please list any dietary restrictions (vegetarian, kosher) you have:

Dietary Restrictions:

6. If you're ready, please...

7. Notes

To save on administrative costs and postage, receipts will be given out at the conference.

Registrations cancelled after the Nov 15 deadline will be assessed a $100 administrative fee.