Crypto `99 Printable Registration Form

Print this form, then fill it out and send by JULY 16, 1999. Further instructions at bottom.

Last Name:
First Name:
Address:
Affiliation:
Phone:
Fax:
Email:
URL:
Sex (M/F):

1.	Full Time Student ($230)	US $
2.	Attended Eurocrypt '99 (Prague) ($415)	US $
3.	Regular Registration Fee ($495)	US $
4.	If your registration is posted after JULY 17, 1999 - ADD $75	US $
	Room and Board (no smoking, 4 nights, Sunday to Thursday, breakfast and lunch Monday to Thursday):
5a.	Single Room ($250)	US $
5b.	Double Room ($190 per person) Roommate's name:	US $
6.	Saturday Night ($70 single; $50 per person double)	US $
7.	Thursday Night ($70 single; $50 per person double)	US $
8.	Extra Guest Attendance for the Social Program only: ($130 per person) Guest's name:	US $
9.	TOTAL FUNDS DUE (US DOLLARS):	US $
	PAYMENT - checks IN US DOLLARS DRAWN ON A US BANK made payable to "U.C. Regents", or by credit card: Card Type: __American Express __Visa __MasterCard Card Number: Expiry Date: Name on card: Cardholder's Signature:
10.	I do NOT wish to be an IACR member (check if applicable)
11.	I do NOT want my details published (check if applicable)

Instructions:

Please type or print clearly.

If you specified a double room, please provide the name of your roommate.

* Instructions for line #10:

When you register and pay for Crypto you will automatically become a member of IACR for the next calendar year free of charge. As a member next year you will receive the IACR (email) Newsletter and The Journal of Cryptology. If you do NOT want to be a member next year, and do NOT want to receive the Journal or Newsletter, check (X) the box on line #10.

* Instructions for line #11:

The personal contact information that you provide is maintained in the IACR Membership Database and will be published in the conference attendees list and the IACR Membership List that is sent to all members every year. It is NOT made available to any other organization in electronic form. If you do NOT want your contact information to be published in the conference attendee list and the IACR Membership List, check (X) the box on line #11.

* How to submit the completed form:

Send the completed form and payment to:

  Crypto Conference
  Campus Conference Services
  University of California
  Santa Barbara, CA 93106-6120

You can also FAX the form to +1 805-893-7287, or send it by EMAIL to iacrmem@iacr.org .