First and Middle Names:                                                                              Last Name:                                                                                

Mail or Fax Form to:

Company/Institution:                                                                                                                                   

PDC 2000 Registration

CPSR

Address:                                                                                                                                                        

P. O. Box 717

Palo Alto CA 94302

City,  State/Province:                                                                                                                                   

Fax: +1 650 322 4748

Postal Code:                                               Country:                                                                                   

Email Inquiries to:

Tel:                                                                                           Fax:                                                                

pdc2000-reg@cpsr.org

Email:                                                                                                                                                              

New Membership in CPSR ($75)$           

I am a member of:  __ CPSR  __ ACM (ACM Member #                              )

Tutorial Fee: ($150)                      $           

__ a Cooperating or Co-sponsor Organization:                                               

Conference Fee:                            $           

____   Full-time student. (Please attach copy of ID or other verification.)

Extra Proceedings:       ___ x $25  $           

____   I have requested a scholarship.

Extra Banquet Ticket:___ x $45   $           

Method of payment:  (Please check one)             

TOTAL FEES:                            $             .

__  Check or money order enclosed, payable to "CPSR/PDC 2000".

Additional Info.:  (optional)

__ Fees paid for by another attendee (name):                                                         

Occupation:

__ MasterCard   or  __ VISA   (we can only process these) Please complete:

Highest Educational Level:

Card #                                                                                                                         Expires:                                                                                  

Registration, Title, or Other Affiliation:

Cardholder’s Name:                                                                                                 

How did you hear about PDC 2000?

Cardholder’s Signature:                                                                                            

Please attach billing address if different from above.