Registration Form:
Late registration will be accepted up to February 28th. A $50.00 late fee will be applied to registration submitted on the day of the conference.
Registration Fee $150.00 (faculty/postdoc) Registration Fee $100.00 ( students)
Registration fee includes banquet and materials
Number of registrations: __________ Total amount:________
Please fill out lines 1-7 for each person attending
Please indicate the method of payment:
□ Check/Money Order (Please make checks payable to ASU Foundation)
□ Credit Card (ASU Foundation will appear on your statement)
□ Visa □ MasterCard □ American Express □ Discover
Credit Card Number:_______________________________ Expiration Date:____________________
Name as it appears on credit card:__________________________________________________
1. Name/Title: ________________________________________________________________ |
2. Mailing Address:_____________________________________________________________ |
3. City, State, ZIP:_____________________________________________________________ |
4. Telephone Number:__________________________________________________________ |
5. E-mail address:_____________________________________________________________ |
6. Affiliated Institution:_________________________________________________________ |
7. Special dietary requests? □ Vegetarian □ other
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Note: A block of rooms has been reserved at the Holiday Inn Phoenix/Tempe under Mathematics of Global Public Health.
Please call 1-800-553-1826 or (480) 968-3451 to book a room. |
Mail check or money order to with this form to: To pay with credit card, fax form to (480) 727-7346 Arizona State University or call (480) 965-2115
Dept of Mathematics & Statistics
MTBI/SUMS Institutes
P.O. Box 871804
Tempe, AZ 85287-1804 |
Contact: Lee Cruz 480 -965-2115 or by e-mail at lee.cruz@asu.edu for further information.
(This payment may not be considered a charitable contribution. All funds will be deposited with the ASU Foundation, a separate non-profit organization that exists to support ASU. (Account # 30-X-MLMA0011) |
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