INFORMATION/REGISTRATION FORM DYNAMICAL SYSTEMS & RELATED TOPICS WORKSHOP October 29 - November 1, 2009 (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: (this appears on your name badge) EMAIL ADDRESS: LODGING DATES: I will arrive at ______(time) on October _____(date) I will depart at ______(time) on November _____(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 October 14, 2009. 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 ___ or 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 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.
