Validation Challenge Workshop Registration Form

(PRINT THIS FORM AND FAX TO: 505-844-4523)

Name: ________________________________________________________________________
Department:_________________________________________________________
Affiliation:___________________________________________________________
Address:____________________________________________________________
State/Providence____________________________________Zip:_______________
Email:__________________________________________
Phone_________________________________________ Fax:________________

REGISTRATION FEES:

	Regular	Amount:
Early Conference Registration (by May 19, 2006)	___ $400	__________

Reception (Sunday, May 21 - 6PM)
(Included in registration Fee) ATTENDING:

Dinner Banquet & Awards (Monday, May 22, 6 PM)
(Included in registratin Fee) ATTENDING:

Dietary Restrictions:_______________________________
X
Guest(s) Name____________________________________	___ $60
(Including yourself and others who may attend)

	TOTAL:	__________

PAYMENT BY CREDIT CARD:

___VISA ___Master Card ___American Express (Check method of payment)

Credit Card #:________________________________ Expiration Date: ________________________
(required) (required)

Name on Card: ______________________________ Signature______________________________
(print name) (required)

FAX REGISTRATION FORM TO: 505-844-4523

PAYMENT BY CHECK OR MONEY ORDER
(in U.S. Funds, no cash accepted)

Payable to: Sandia National Laboratories, VCW2006

Mail payment with registration form to:

Sandia National Laboratories, VCW
Attn: Steve Kranz, Conference Coordinator
PO Box 5800, MS0833
Albuquerque, NM 87185-0833