ISMVL 2004 GENERAL REGISTRATION FORM

First name: ______________________________ Middle name(s): ____________________

Family name: ____________________________Title [Prof., Dr., Mr., Ms., etc.]: ________

Address (Please write details, make sure that mail can reach you at the address you provide)

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Phone:_____________________ FAX:___________________ E-mail: _________________

Registration fee

  On or Before April 15, 2004 After April 15, 2004
      US Dollars        CAD Dollars         US Dollars        CAD Dollars    
IEEE Member $310 $410 $370 $490
Non-member $390 $520 $500 $670
Student $85 $110 $150 $200

PAYMENT: [Check one box: Credit card payment is preferred.]

Fill out this form, sign, and fax to Prof. Ali Sheikholeslami, Symposium Chair, at
(416) 971-2286. For more information, visit the ISMVL 2004 Website:
http://www.eecg.utoronto.ca/~ali/ismvl2004