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| <p><strong>REI-2005</strong>: The 13th International Conference on</p> |
| <p><em>Radiation Effects in Insulators</em></p> |
| <p>Santa Fe, New Mexico, USA </p> |
| <p>28 August - 02 September, 2005</p> |
| <p><strong>Registration Payment Form</strong></p> |
| <p><strong>Family Name (last name):</strong></p> |
| <p><strong>Given Name (first name):</strong></p> |
| <p><strong>Electronic Mail Address:</strong></p> |
| <p><strong>CONFERENCE FEES (Pre-registration deadline June 10, 2005):</strong></p> |
| <p><strong>Regular Attendee, Pre-registration $475.00 USD</strong></p> |
| <p><strong>Regular Attendee, Post-registration $550.00 USD</strong></p> |
| <p><strong>Student Attendee, Pre-registration $375.00 USD</strong></p> |
| <p><strong>Student Attendee, Post-registration $450.00 USD</strong></p> |
| <p>There are 3 methods of payment for conference registration: (1) a personal check drawn on a U.S. bank; (2) direct bank transfer into the conference bank account; (3) credit card transaction (Visa or MasterCard only).</p> |
| <p>(1) Personal Check. Mail personal check (drawn on U.S. banks only!) made out to “<strong>REI-2005</strong>” to:</p> |
| <p><strong>Kurt Sickafus, REI-2005 Co-Chair</strong></p> |
| <p><strong>Los Alamos National Laboratory</strong></p> |
| <p><strong>MS-G755</strong></p> |
| <p><strong>Los Alamos, NM 87545 USA</strong></p> |
| <p>(2) Bank Transfer. Send registration fee via bank transfer directly to:</p> |
| <p><strong>Los Alamos National Bank</strong></p> |
| <p><strong>1200 Trinity Dr.</strong></p> |
| <p><strong>Los Alamos, NM 87544 USA</strong></p> |
| <p><strong>Account No.: 00-256501-01</strong></p> |
| <p><strong>Bank Routing No. (IBAN No.): 107001012</strong></p> |
| <p>[Participants are responsible for ALL bank transfer fees. You will be billed at the Conference for any outstanding balance on your account.]</p> |
| <p>(3) Credit card transaction. Fill out the information below, print the form, and FAX this form directly to:</p> |
| <p><strong>Kurt Sickafus, REI-2005 Co-Chair</strong></p> |
| <p><strong>FAX #: 505-667-6802</strong></p> |
| <p><em>Method of Credit Card Payment</em>: □Visa □MasterCard </p> |
| <p>Name on Cardholder’s Card: __________________________ </p> |
| <p>Credit Card Number: _____________________________ Expiration Date: _________</p> |
| <p>3 digit security code on back of card: ______</p> |
| <p>Billing Address for Card: ______________________________________________________________</p> |
| <p>______________________________________________________________</p> |
| <p>Cardholder’s Signature: ________________________________________________________________________</p> |
| <p>(Note: Payment cannot be processed without the cardholder’s signature.)</p> |
| <p>A receipt will be mailed to you within two weeks of receipt of registration fees, based on any of the 3 payment methods described above.</p> |
| <p>Questions? Contact:</p> |
| <p>Kurt Sickafus, REI-2005 Co-Chair</p> |
| <p>Los Alamos National Laboratory</p> |
| <p>MS-G755</p> |
| <p>Los Alamos, NM 87545</p> |
| <p>505-665-3457 (ph.) /505-667-6802 (Fax)</p> |
| <p>kurt@lanl.gov</p> |
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