REGISTRATION FORM FOR ELECTRONICS PACKAGING SYMPOSIUM – OCTOBER 9-10, 2012
NAME:
TITLE:
DEPARTMENT:
ORGANIZATION/COMPANY
ADDRESS:
CITY, STATE, ZIP:
PHONE:
EMAIL:
NATIONALITY (required by GE):
CITIZENSHIP (required by GE):
☐ US CITIZEN
☐ US PERMANENT RESIDENT
☐ OTHER
SPECIAL DISABILITY
ASSISTANCE/DIETARY
REQUEST:
I am registering as: (please check your choice)
Early Bird
(before or on Sept. 4, 2012)
$450
☐
Industry
Regular
(Sept. 5, 2012 - Oct. 3, 2012 )
$500
☐
Industry Group Rate (20 or more - please include
attendee names and titles on a separate sheet)
☐
$250
☐
$300
Non-Profit / Government / Academia
☐
$325
☐
$375
Student (non-Binghamton University)
☐
$125
☐
$175
Binghamton University Faculty/Staff/Student
(fees covered by IEEC, advance registration required)
Co-Chair or Invited Speaker
(fees covered by IEEC, advance registration required)
☐
$100
covered by IEEC
$100
covered by IEEC
☐
$100
covered by IEEC
$100
covered by IEEC
☐
Please apply IEEC Member Benefit Discount:
☐ Full Member:
80% off for 3 seats
☐ Participating Member: 80% off for 1 seat
☐ Associate Member:
50% off for 1 seat
Continued on next page
☐
REGISTRATION FORM FOR ELECTRONICS PACKAGING SYMPOSIUM – OCTOBER 9-10, 2012
Page 2
I am attending as a: ☐ Co-Chair
☐ Invited Speaker
☐ Poster Presenter
☐ General Attendee
I will be arriving to GE Global Research Center by: (required by security/parking)
☐ Personal Vehicle
☐ Rental Car ☐ Taxi
☐ Carpooling
I will be attending the following meals:
DAY 1 (October 9, 2012): ☐ BREAKFAST
DAY 2 (October 10, 2012): ☐ BREAKFAST
☐ LUNCH
☐ LUNCH
☐ DINNER
I am interested in receiving a Continuing Education Unit (CEU) certificate: ☐ Yes
☐ No
I am paying by:
☐ CHECK (payable to Research Foundation Award 54401 )
☐ PURCHASE ORDER # __________________
☐ CREDIT CARD (VISA or Mastercard Only. We will call you by phone after this form is received to
obtain your credit card information.)
☐Charges to be covered by the IEEC at Binghamton University.
Provide B# (if BU student/faculty/staff)___________________ or indicate on the top of this page
that you are a co-chair or invited speaker.
You may return this form to Lisa Altman by email, fax or mail:
EMAIL: wtsnindy@binghamton.edu
FAX: 607-777-6256
MAIL: Lisa Altman, Office of Industrial Outreach
Watson School of Engineering and Applied Science
Binghamton University
PO Box 6000
Binghamton, NY 13902-6000
For Questions: Contact Lisa Altman at 607-777-2154 or email wtsnindy@binghamton.edu