Please send this form to ONE of the following * Dirk.Stroobandt@UGent.be with subject line "SLIP 2006 registration" * fax no. +32 9 264 35 94 "to the attention of Dirk Stroobandt" * surface mail address: Dirk Stroobandt UGent - ELIS Sint-Pietersnieuwstraat 41 B9000 Gent, Belgium ********* SLIP 2006 Registration form ********* "*" marks required information! Title (Prof., Dr., ...): ........ *First name: ........... Middle initial(s): ..... *Last name: ..................................... *Institution: ................................... *Country: ....................................... *E-mail: ........................................ Fax number: ..................................... Phone number: ................................... Registration fees: Advance registration On-site IEEE/ACM/SIGDA members 275 USD 350 USD non-members 375 USD 425 USD student members 150 USD 200 USD student non-members 250 USD 250 USD The advance registration deadline is February 17th, 2006. To be eligible for the reduced registration fee for IEEE/ACM/SIGDA members, please fill out one of the following: IEEE membership number: ......................... ACM membership number: .......................... SIGDA membership number: ........................ To be eligible for the student discount, please provide the institution where you are a student, as well as your student card number. Be prepared to show your student card at the registration desk. Student at: ..................................... Student card number: ............................ Registration fee: ........... USD Additional items: Additional copies of the proceedings: .... x $25 = USD ..... Additional lunch tickets for Saturday: .... x $50 = USD ..... Additional lunch tickets for Sunday: .... x $50 = USD ..... Additional Sunday afternoon tickets: .... x spouse/children tickets (free, limited to availability) .... x tickets for friends: .... x $10 = USD ..... Total fee for additional items: ............ USD Other requests (please tick with "X" if applicable): I am a vegetarian: ........ Method of payment (please tick with "X" if applicable): .... I will make a check to "ACM-SLIP06" for "SLIP 2006 registration" to the following address: Prof. Dirk Stroobandt UGent - ELIS Sint-Pietersnieuwstraat 41 B9000 Gent, Belgium (checks should have arrived by February 17th, after that date they will only be accepted at the workshop registration desk) .... I pay by VISA .... I pay by Mastercard .... I pay by American Express Total amount to be paid: ......... USD Card number: .................................... Name on card: ................................... Expiration date: ........ / ....... Security code (last three figures on back side of card): ...... Your name or signature (if sending by surface mail or fax): ....................................... Date signed: ............ CANCELLATION POLICY Cancellations must be received by February 24, 2006 and are subject to a $50 cancellation fee.