CEC/EEE06 Registration Step 2

Page 1 of 1

Step 2: Please print this page and FAX or mail with your payment to the address at the bottom of this
form.

CEC/EEE06 Registration:
Registration Number : 072
First
Name:

Dirk

Last
Name:

Bergemann

Department of Economics, Yale University

Country: USA
Email: dirk.bergemann@yale.edu
Affiliation:
IEEE
Member:

80450402
$480

Conference Fee:
Extra Banquet tickets:
Extra Page Charges:
Total Due:
Payment Method:

$480.00
Credit Card

Wire Transfer

Cashier's Check

For payment by Credit card:

(Please enter the credit card information below, and fax us a copy of the page with
your signature on it. This page will not be sent over Internet.)
Card
Card
MasterCard
5405015418671416
Number:
Type:
Exp Date
Name on
Dirk Bergemann
10/06
(MM/YY):
Card:
Billing
28, Hillhouse Avenue
Address:
Total
480.00
Signature:
Amount :
Please fax this page (with your credit card info filled) to:
fax: +1-949-824-2321
tyu1@uci.edu
For payment by Wire Transfer:
Account No.: 11010-42154
Swift Code: 121000358
Bank Name: Bank of America (CA6-167-01-01)
Bank Address: 4101 MacArthur Boulevard, Newport Beach, CA 92660,USA
Account Holder's Name: IEEE (CEC 2006)
Payment Info: [your registration number]
For payment by cashier's check:
Please mail this page with check (with registration number on the check) to the
following address:
Prof. Kwei-Jay Lin
Dept EECS, Univ. California, Irvine
Irvine, CA 92697-2625 USA

Print

http://linux.ece.uci.edu:8080/cec06/process.jsp

4/24/2006