Postscript version of this form
 Register for the Workshop:

Please print out and fill out this form. Then mail the form and your payment to

DWTA '97 Registration
c/o Prof. George Cybenko
8000 Cummings Hall
Thayer School of Engineering
Dartmouth College
Hanover, NH 03755-8000

Or, if paying by credit card, you can fax the form to George Cybenko, 603-646-2277.
Contact Information
First name:
____________________ Last name: _________________________
Title:
____________________________________________________________
Organization:
____________________________________________________________
Street address:
____________________________________________________________
City:
_____________________________ State: _______________
Country:
_____________________________ ZIP/Postal code: _______________
E-mail address:
____________________________________________________________
URL:
____________________________________________________________
Telephone:
____________________ FAX: ____________________
Payment Information
Payment method:
__ Check __ Purchase order __ Visa __ MasterCard
(Before Sept. 5) __ Member* ($110.00) __ Non-member ($138.00) __ Student ($60.00)
(After Sept. 5) __ Member* ($132.00) __ Non-member($166.00) __ Student ($72.00)

* Member of IEEE, IEEE Computer Society, or Dartmouth Center for Mobile Computing

If you are a member of IEEE, please provide your member number.

IEEE Member Number ____________________

If paying by credit card, please provide your credit card information. Please print clearly.

Card Number _________________________ Exp. Date _________________________
Cardholder Name _________________________ Signature _________________________