Multiscale Closing Workshop Registration

Statistical and Applied Mathematical Sciences Institute
19 T. W. Alexander Drive
P.O. Box 14006
Research Triangle Park, NC 27709-4006
Tel: 919.685.9350 FAX: 919.685.9360
info@samsi.info

Multiscale Model Development and Control Design
September 27-28, 2004

Closing Workshop Registration

To apply to attend the Workshop, or for travel support, please fill out the form below, and then click the SUBMIT APPLICATION button. Items in red are required. Following submission, a confirmation of your application will be displayed. (Print a copy for your records.)

REGISTRATION DEADLINE: September 23, 2004 at 12:00PM

SAMSI Travel Policy

Registration Fees

	Workshop
Student	$10
Faculty/Professional	$20

Fees are due upon your registration. SAMSI accepts check, Visa, or MasterCard.

for Credit Card Payments:

Fill out the payment form (PDF file)
Fax it to (919) 685-9360

for Check Payments:

Fill out the payment form (PDF file)
Mail the form and check (payable to SAMSI) to:

SAMSI
Attn: Multiscale Closing Registration
PO Box 14006
Research Triangle Park, NC 27709-4006

In order to guarantee proper credit to your registration, SAMSI must RECEIVE payment by September 24, 2004.

Participant Information

Name

Title

Organization

Department

Address

City State Zip (or Postal) Code

Country Required if not US

Telephone (Format: xxx-yyy-zzzz)

FAX (Format: xxx-yyy-zzzz)

E-mail

URL

Interest in the Program

Please describe briefly your background and reasons for wishing to participate in the program in 100 words or less.

Request for Financial Support

I wish to apply for financial support. Support levels will be determined by SAMSI, but will in no case exceed reimbursement for travel and housing expenses supported by proper receipts. For SAMSI's records and reports, applicants for support are requested to E-mail a brief CV or resume (the 2-page format used for NSF proposals is ideal) to multiscale-closing@samsi.info. New researchers and members of under-represented groups are especially encouraged to apply.

NISS Affiliates and NISS/SAMSI University Affiliates Only

Check this box if you are from a NISS Affiliate and plan to request reimbursement from your NISS/SAMSI Reimbursement Account.

Graduate Students Only

Please check the box below, and in the "special request" block, identify your advisor and dissertation topic.

I am a graduate student.

Invited Speakers

If you are an invited speaker, please provide the title of your presentation here. The abstract should then be emailed to multiscale-closing@samsi.info.

Title:

Special Requests

If you have special requests (such as dietary restrictions), please enter them below. Other questions should be sent by E-mail to multiscale-closing@samsi.info.

Submission

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