Regular Mail or FAX - Registration Form

Fall Meeting of the Illinois and Iowa Sections of AAPT
October 29-30, 1999,
Augustana College, Rock Island, Illinois

Name:  ________________________________________________________________

Address - line 1:  _________________________________________________________

Address - line 2:  _________________________________________________________

City, State ZIP: __________________________________________________________

Telephone: (______)_______________ Ext.__________ FAX: (______)_____________

E-mail:  ________________________________________________________________

Institution (to appear on your name tag):  _______________________________________

I would like to do a "Take Five" presentation on ___ Fri. afternoon,  ___ Sat. morning,  ___ Sat. afternoon.

The title of my Take Five presentation is: __________________________________________________

Description Number Unit cost Amount Circle your choice
Faculty registration   $ 16    
Student registration   $ 5  
Illinois section dues   $ 5  
Iowa section dues   $ 5  
Workshop W1 - Friday at 1:30   free ----
Workshop W2 - Friday at 1:30   $ 10  
Workshop W3 - Saturday at 1:00
This workshop is full.
  $ 10  
Workshop W4 - Saturday at 1:00   free ----
Workshop W5 - Saturday at 1:00   $ 10  
Friday evening banquet*   $ 12  

Fish, Chicken or Vegetarian

Saturday noon box lunch*   $ 6  

Turkey, Ham or Vegetarian

Total fees ---- ----    

*The Friday banquet and the Saturday noon box lunch are available only to those who have registered by the October 22 deadline.  Please make your check payable to ISAAPT and include it with the registration sent via US Mail.  If registering by FAX or online, the registration amount will be due upon arrival.  Please return this registration form to:

David Renneke
Department of Physics and Astronomy
Augustana College
Rock Island, IL 61201-2296

Voice: (309) 794-3403
FAX: (309) 794-7722
e-mail: phrenneke@augustana.edu

Last update: October 14, 1999