41st Midwest Theoretical Chemistry Conference (MWTCC)
Registration Form
After filling out the registration form, please save file using the presenting author’s name as the file name
(for example, Yunxiang_Pan.pdf). Completed registration form should be emailed to
MWTCC@chem.siu.edu
Name
Prefix
First
Dr.
Stefan
Initial
Last
Suffix
Tsonchev
Email address
Gender
M
Nickname (if preferred for badge)
S-Tsonchev@neiu.edu
University/Company
Northeastern Illinois University
Mailing address
Line 1 (Department/Mail Stop)
Line 2 (PO Box)
Department of Chemistry
Northeastern Illinois University
Line 3 (Street Address)
City
State
Zip
Chicago
IL
60625
Presentation
Title: Micro and Nanoscale Self-Assembly: Theory and Modeling
Presentation Preference
AV requirements if you select oral
X Poster
Computer Projector
Oral (To be confirmed by May 12)
Overheads
Registration
Position
Registration Fee
Student
($30)
X Other
($60)
On-site Friday Lunch ($11.00) Special Dietary Requirements
Accompanying guest for
Vegetarian
Friday dinner ($25.00)
Other (describe)
Lodging
X Off site
(you are
responsible
for your own
arrangement
– see list of
local hotels)
On site (rank 1st－5th choices, use “U” for choices that
are unacceptable. Fees will be due at the meeting.)
Little Grassy Lodge (1-person): $62.00/night
Little Grassy Lodge (2 shared): $30.74/night
Morris or Shawnee Dorms (2 shared): $19.00/night
L.B. Sharp Dorm (4 shared): $11.00/night
Cabin (8 shared): $8.00/night w/$8 for linens (one-time
charge)
Nights needed
Thursday May 28
Friday May 29
Saturday May 30
Roommate request
(names)
Payment of registration
Make a check payable to “Dept. of Chem. & Biochem. SIUC” and send it via regular mail to:
MWTCC
c/o Kim Doellman
Department of Chemistry and Biochemistry
Southern Illinois University
Carbondale, IL 62901
Note: Please write your name(s) on the back of the check if no such info is provided on the front.