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 | |||
| $ 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 |
Last update: October 14, 1999