MCCCC Conference Registration
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Please note that the institutional addresses seem to be more stable
than home addresses, and that forwarding orders don't last long.  
Please include your department in your institutional address.
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FIRST NAME: 	______________________________________________
	
LAST NAME:	______________________________________________

INSTITUTION & DEPARTMENT:	______________________________________

				______________________________________

OFFICE ADDRESS:			______________________________________
		
CITY/STATE/ZIP:			______________________________________

OFFICE PHONE:			__________________________

HOME PHONE:			__________________________

EMAIL ADDRESS:			______________________________________


METHOD OF PAYMENT:  (Indicate the method of payment)

[ ] PAYMENT BY CHECK  (Make check payable to Wichita State University)

[ ] PAYMENT BY CREDIT CARD    Provide the following informaiton:

    VISA/MASTERCARD # __________________________   EXP. DATE ________


REGISTRATION FEE:   (Indicate appropriate fee)

If received BY SEPTEMBER 30:
		
    	[ ] $85.00	

	[ ] $35.00 (Students and Retired or Unemployed mathematicians)

After September 30:

	[ ] $100.00 

	[ ] $50.00 (Students and Retired or Unemployed mathematicians)


PLEASE COMPLETE THE FOLLOWING INFORMATION:
Do you need a parking permit during the conference?   [ ] YES	[ ] NO
Are you presenting a paper?			      [ ] YES	[ ] NO

CANCELLATION POLICY (REFUNDS/CANCELLATIONS):
A refund of the full amount paid, less $10, will be made upon request 
if received prior to the first meeting of the conference.  No refunds 
will be made thereafter.

Mail completed registration form and fees to:
			MCCCC
			Department of Mathematics & Statistics
			Wichita State University
			1845 N. Fairmount
			Wichita, KS  67260-0033