Registration Form for STACS '97

Please fill in (type or use block letters) and return this form with proof of payment to Rüdiger Reischuk, c/o STACS'97, Universität Lübeck, Institut für Theoretische Informatik, Wallstraße 40, D-23560 Lübeck, Germany.

Mr, Ms, Acad. Title: _______________________

First Name: _______________________________________________________________

Name: ____________________________________________________________________

Institute: __________________________________________________________________

Address: __________________________________________________________________

__________________________________________________________________________

Country: __________________________________________________________________

Phone: ____________________________________________________________________

FAX: _____________________________________________________________________

Email: ____________________________________________________________________

WWW: ___________________________________________________________________

AFCET-GI No.: ____________________________________________________________

Dietary restrictions: Vegetarian: ______________ None:

Guided city tour: Yes No

The fees are listed below, all prices are in DM:

early registration until 1/20/1997
normal special (*) else
AFCET-GI member 350,- 320,- 400,-
Non-member 400,- 370,- 450,-
Student 220,- 190,- 270,-
Confernce dinner,
additional ticket 		100,- 100,- 100,-

Students must include a letter from their department or supervisor verifying student status.

Registration fee:
DM: ____________________
Additional conference dinner and
excursion tickets (DM 100,-), # : _____
DM: ____________________
Total amount:
DM: ____________________

Check (in DM) is enclosed.

The money has already been transferred to Commerzbank Lübeck (BLZ 230 400 22, SWIFT-Code: COBADEFF230), Breite Str. 52, D-23552 Lübeck, Account Rüdiger Reischuk, keyword STACS'97, Acct. No. 01100 6400.

I duly authorize you to charge my

Eurocard/Mastercard VISA Diners

Credit card # ________________________________________________

Expiration date ______________________________________________

Cardholder's name ___________________________________________

Date: _______________ Signature: _____________________________

Date: _______________ Signature: _______________________________________________