Pre-Registration Form

Fall 2004 NES/MAA Meeting, November 19-20, 2004



Please print this form and print or type in the requested information.


Name:                                                                                         Affiliation:

E-mail:

Telephone:

Address:






Please check one of the following:

University faculty:

    ___           

Four-year college faculty:

    ___           

Two-year college faculty:

    ___

High school faculty/administrator:

    ___           

Business/Industry/Government:

    ___           

Retired:

    ___

Graduate Student:

    ___           

Undergraduate:

    ___           

Unemployed:

    ___


Please check:    Male ___   Female ___

Pre-registration Fee:

MAA Member  ($25)

Non-member   ($30)

Student or unemployed   ($10)

$_______


Meals:

Friday Banquet   ($30 per person)

  ____   x $30    =    

$_______

       Choose entrees:     ___ x Beef

                                         ___ x Fish

                                         ___ x Vegetarian

Saturday Luncheon   ($18 per person)

  ____   x $18    =    

$_______


Total Payment

$_______



Will you attend Project NExT?    Yes ___   No ___

Mail form and payment by Monday 1st November, 2004 to the Program Committee Chair:

                Prof. Suzanne L. Weekes - NES/MAA
                Department of Mathematical Sciences
                Worcester Polytechnic Institute
                100 Institute Road
                Worcester, MA 01609

Checks should be payable to: NES/MAA

Return to   Fall 2004 NES/MAA Meeting website.