PLEASE FAX OR EMAIL THE FORM BELOW FULLY FILLED OUT WITH YOUR PAYMENT INFORMATION.
       NOTE THAT REGISTRATION WILL NOT BE CONFIRMED UNTIL WE HAVE RECEIVED PAYMENT.
                           email: imc2004-taormina@acm.org
                          FAX: +39-090-43-931 attn: IMC 2004

                            REGISTRATION FORM FOR IMC'04

PARTICIPANT INFORMATION


Name (first, middle, last):_________________________________________________

Affiliation (for badge): ___________________________________________________

Title/Job Function: ________________________________________________________

Address: ___________________________________________________________________

City: ________________ State: ________________ Zip Code: ___________________

Country: ___________________ Email: _____________________________________

Phone: (____)___________________________ Fax: (_____)_______________________

Email address (mandatory for confirmation): ________________________________

ACM/SIG or USENIX Member ID: ____________________ Student ID: _____________

Special Meal Requirements (circle one): Vegetarian -- Kosher -- Vegan

Special Needs: ______________________________

Do not include my name, address and e-mail in the attendee listing _____ 
(note that the list will be published in a non-machine-readable format)

Conference fees: ________

ACM membership: ________

Extra social program participant: ____ x $112 = ______

Total Fees:  _____________

PAYMENT METHODS

    CREDIT CARD Payment included (circle one):

    American Express -- Master Card -- Visa

    Credit Card Number: ___________________________ Expiration Date: _____________

    Names as appears on Credit Card: _____________________________________________

    Signature: ___________________________________________________________________

    Credit card statement will read ACM New York, NY

CHECKS

    Make checks payable to ACM/IMC'04 Conference. Mail check with registration 
    form to: ACM Member Services, P.O. Box 11405, New York, NY 10286-1405, USA