REI-2005: The 13th International Conference on

Radiation Effects in Insulators

Santa Fe, New Mexico, USA

28 August - 02 September, 2005

Registration Payment Form

Family Name (last name):

Given Name (first name):

Electronic Mail Address:

CONFERENCE FEES (Pre-registration deadline June 10, 2005):

Regular Attendee, Pre-registration $475.00 USD

Regular Attendee, Post-registration $550.00 USD

Student Attendee, Pre-registration $375.00 USD

Student Attendee, Post-registration $450.00 USD

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).

(1) Personal Check. Mail personal check (drawn on U.S. banks only!) made out to “REI-2005” to:

Kurt Sickafus, REI-2005 Co-Chair

Los Alamos National Laboratory

MS-G755

Los Alamos, NM 87545 USA

(2) Bank Transfer. Send registration fee via bank transfer directly to:

Los Alamos National Bank

1200 Trinity Dr.

Los Alamos, NM 87544 USA

Account No.: 00-256501-01

Bank Routing No. (IBAN No.): 107001012

[Participants are responsible for ALL bank transfer fees. You will be billed at the Conference for any outstanding balance on your account.]

(3) Credit card transaction. Fill out the information below, print the form, and FAX this form directly to:

Kurt Sickafus, REI-2005 Co-Chair

FAX #: 505-667-6802

Method of Credit Card Payment: □Visa □MasterCard

Name on Cardholder’s Card: __________________________

Credit Card Number: _____________________________ Expiration Date: _________

3 digit security code on back of card: ______

Billing Address for Card: ______________________________________________________________

______________________________________________________________

Cardholder’s Signature: ________________________________________________________________________

(Note: Payment cannot be processed without the cardholder’s signature.)

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.

Questions? Contact:

Kurt Sickafus, REI-2005 Co-Chair

Los Alamos National Laboratory

MS-G755

Los Alamos, NM 87545

505-665-3457 (ph.) /505-667-6802 (Fax)

kurt@lanl.gov