PLoP 2005 Registration

Personal Information
First Name:*
 		 Last Name:*
 
Street Address 1:
Street Address 2:
City:
 State / Region:
Zip or postal code:
 Country:
Organization / Affiliation:
Phone Number:
 Fax Number:
E-mail Address:*
 
WWW Address:

 

Status Information
  
First time PLoP attendee
Author of an accepted paper
Full time student
Have your own accommodations and won't be staying at the Allerton House
Shepherd
Prefer a smoking room assignment
Vegetarian
PLoP'05 approved volunteer
Program Committee Member
  T-Shirt Size
Bootcamp ($300 includes extra night stay September 6th & Food on the 7th)
Please choose room type* 
Single = $999.00 for conference
Double = $919.00 for conference
(Only 15 single rooms available, requests are made first come first served)

 

Travel Information
   

Date:

 Arrival:
 		Departure:
  Note: Bootcamp attendees should arrive on 9/06/2005.
Comments:

 

 Credit Card Information
For security reasons, we are having you write in your credit card number on a printed out copy of the next page and then you will fax it to us.

If you are a volunteer, whose registration is waived, then select volunteer for card type and enter 99999 for expiration date and customer code, and your full name in the Credit Card Billing Name field.

Card Type:*
 

Card's Expiration Date:*
  MM/YY

Card's Customer Code:*
  See Example
Full Name as Printed on Card:*
 

 

Billing Address for Credit Card:
(if different from mailing address above)
Street Address 1:
Street Address 2:
City:
State / region:
Zip or postal code:
Country: