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On-line Registration Form:

Name of Attendee:
Last/Family Name:
First/Given Name:
Middle Initial/Name:
Name you wish to be called (for your badge):


Institutional affiliation:
Address:
City:
State/Province: (If applicable)
Country:


Phone:
FAX:
E-Mail Address:
Please Repeat E-Mail Address:


Level of participation:

Full registration:
Includes Symposium, Friendship Reception Thursday night, Lunch Friday, Banquet Friday night): $ 200.00

Invited speakers only:
Full registration (includes Symposium, Friendship Reception Thursday night, Lunch Friday, Banquet Friday night): No Charge

Student registration:
Attendance at Symposium only (includes Symposium and coffee breaks, Thursday night reception, lunch on Saturday but the Thursday night banquet and lunch on Friday would be extra, see below to purchase banquet ticket): $ 50.00


Optional items:

Friendship Reception only (April 7): $ 35.00

Banquet only (April 8): $ 60.00

Lunch on Friday (April 8): $ 10.00


Saturday lunch at the Geil farm:

I am planning to join in this "farewell" event to all those attending:
Yes No Don't know

Contribution to Scholarship Fund in Honor of Prof. Geil's 75th Birthday:
$ 10.00 $ 25.00 $ 50.00 $ 100.00 $ 250.00        Other: $



You can charge all fees to any of the following credit cards:

NOTE: All credit card charges will be processed using the credit card
facility of SPI Supplies/Structure Probe, Inc. so please remember that this
is how the charge will be coming through on your credit card statement.
Credit Card Payment:
Credit Card # :
Expiration Date : /
Exact Name on credit card :
Billing Address for credit card:
City:
State:
Other:
Postal Code/Zip Code:
Country:



Does your employer have a "matching funds" program for such contributions?
Yes No Don't know

Are you interested in becoming a sponsor of the Symposium?
Yes No

Are you a former student of Prof. Geil?
Yes No

If yes, please check appropriate boxes:
Case Western Reserve University
University of Illinois
What years (please tell us when)
Note: A list of attendees will be published at the time of the Symposium.
I do      do not want my name and contact information to be listed on the attendee list.

Would you like to make any comments or suggestions? Or would you just like to send a personal "hello" to Prof. Geil? Just use the box below and we will make sure your comments are sent to the right place! We look forward to this exciting event in Champaign/Urbana in 2005!