PSU Mark
Eberly College of Science Mathematics Department

Registration Form

INFORMATION/REGISTRATION FORM

DYNAMICAL SYSTEMS & RELATED TOPICS WORKSHOP

October 20 - 23, 2011

(Please complete and return to shaffer@math.psu.edu as soon as possible)

NAME:_________________________________

TITLE: (check one) Professor ___ Postdoc ___ Grad Student ___

YOUR GENDER: (check one) Male ___ Female ___

UNIVERSITY AFFILIATION: 

EMAIL ADDRESS:

LODGING DATES: I will arrive at ______(time) on October _____(date)

I will depart at ______(time) on October _____(date)

ARE YOU WILLING TO SHARE A DOUBLE ROOM? Yes___ No___
If YES, with whom? ________________________

We will try to accommodate rooming requests with those who will arrive and depart on the
same days in the block of rooms set aside at the Sleep Inn, Atherton Hotel or Days Inn
under the "Dynamical Systems Workshop" group name. The cutoff date for hotel reservations
is September 19, 2011.

You will be responsible to inform the organizers immediately of any changes to your
lodging accommodations should you decide to change your arrival/depart days or if you
should decide not to attend by emailing dsws@math.psu.edu.

REMINDER: You should plan on paying for your lodging at the hotel.

PLEASE NOTE: We appreciate if you could pay your lodging from your own grants to provide
additional support to help allow young people to attend. However, if you need assistance
with support, funds are available for partial support for participants which normally
consists of reimbursement of a shared double room (room & tax only).

If interested in obtaining support, please check here: YES ___ NO _____

For any reimbursements, you must see Hope Shaffer to complete the necessary forms upon
arrival. ORIGINAL RECEIPTS ARE REQUIRED. We will do reimbursement processing after you
have mailed us your original lodging receipt (room & tax only) for half of the cost of a
shared double room after the end of the workshop.

ARE YOU AN AMERICAN CITIZEN? Yes___ No___

IF YOU A FOREIGN NATIONAL, ENTER THE TYPE OF VISA WRITTEN ON YOUR "I-94 ENTRY TO THE
UNITED STATES CARD": (please check one below)

__B-1, __B-2, __*J-1, __J-2, __F-1, __H-1, __TN,
__WB, __WT

__ Permanent Resident (Green Card),
__ Employment Authorization Card

*IF YOU HAVE A J-1 VISA, IT IS VERY IMPORTANT TO INFORM ME OF 
WHICH UNIVERSITY INITIATED YOUR VISA. PLEASE PROVIDE NAME OF 
CONTACT PERSON AND ADDRESS OF THE UNIVERSITY WHO SIGNED YOUR 
DS-2019 FORM.

Name:
Address:
University:
Fax & Phone Numbers:

IMPORTANT: If you are a foreign national, please remember to 
bring your passport/visa papers, etc. with you to the conference.

Would you like to give a contributed talk:
Title:
Please send your abstract to: dsws@math.psu.edu

Any questions, please contact:
Hope Shaffer
Conference Staff Assistant
Department of Mathematics
107A McAllister Building
University Park, PA 16802

Telephone: +1 814 863 9017
Fax: +1 814 865 6073
shaffer@math.psu.edu