Last Name:_________________________First Name:___________________
Full mailing address:
Line One:________________________________________________________
Line Two:________________________________________________________
City:_____________________________State:_______Zip:______________
Tel:______________________________E-mail:________________________
Fax:______________________________
Current affiliation:_____________________________________________
Your Professional Background:
[ ]Faculty Member [ ]Post Doc [ ]Graduate Student
[ ]Employee of Industry [ ]Member of an IMA Member institution
[ ]Other