NSF-CBMS Regional Research Conference:
Mathematical Methods in Nonlinear Wave Propagation

Department of Mathematics
North Carolina A&T State University
Greensboro, North Carolina
May 15-19, 2002

Conference Registration and Request for Support Form

Deadline:
Support Requests and Poster Presentation Abstracts: April 15, 2002 (or until funds run out!)

REGISTRATION

Salutation:
Last Name*:
First Name*:
Middle Initial:
Exact Name on Tag:
Affiliation*:
Professional Status:
Address*:
City*:
State*: Zip Code:
Phone Number*:
Fax Number:
E-mail:
Arrival Date*:
Departure Date*:

* means a required field. You will have to fill in the blank; othewise the form will not be processed.

I will attend the Welcome Dinner on Wednesday, May 15th.
Cost: Free if registered by April 15; $15 if registered after April 15.

I will need a visitor's parking permit while attending the conference.

Please describe any special needs:

Registration Fee: $35 ($50 after April 15) covers all conference refreshments.
Please make your check payable to: NC A&T Mathematics Department, and mail it to: S.D. Burns, Department of Mathematics, North Carolina A&T State University, Greensboro, NC 27411. (Please contact the organizers if you need assistance.)

OPTIONAL DEMOGRAPHIC INFORMATION

The following demographic data is requested on a valuntary basis:

Ethnic background:
Gender: Male       Female
Highest degree: Received       Expected      
Date highest degree
received or expected:
Type of Institution:
Research intensive:

FINANCIAL SUPPORT REQUEST

If you are requesting financial support, please provide the following information, additional to above, BEFORE YOU TRAVEL. Failure to provided any of the requested information in a timely manner will result in delay of processing your reimbursements, or even failure to reimburse.

Social Security Number for US resident:
I9# of valid visa or I10# of visa waiver
for non-US resident:

You will be required to use US flagged flights whenever such flights are available if you are supported.
Arrival Time:
Departure Time:

If your arrival and departure times are not available at this time, please send that information to S.D. Burns at sburns@ncat.edu soon after you have it but definitely before you travel.

Support requested for:
Lodging: Yes     No
Meals (Only those with proper
receipts will be reimbursed):     		Yes No
Travel (as long as funds permit!): Yes No

Will you be able to attend the conference if you get
partial support:    Yes     No
no support: Yes No

Your home address:
Street:
City:
State: Zip Code:

Please sign your reimbursement form BEFORE you leave the conference to expedite refunds.

Thank you very much for your interest in our conference and taking the time to complete this form. We will inform you the support decision once it is reached. We look forward to seeing you in Greensboro in May.

Alternatively, you may print and mail this form with your registration check to:
S.D. Burns, Department of Mathematics, North Carolina A&T State University, Greensboro, NC 27411.