GOMACTech-12 REGISTRATION FORM
March 19 - 22, 2012
Bally's Hotel, Las Vegas, NV
www.gomactech.net

ADVANCE REGISTRATION MUST BE RECEIVED NO LATER THAN 9 MARCH 2012
CANCELLATION/REFUND DEADLINE: 9 MARCH 2012
PART I. NAME AND ADDRESS 

Last Name
First Name
Initial

Rank or Title

Company/Gov't Agency/University

Affiliation Address (Street/Avenue)
Mail Stop/P.O. Box/Code

City
State
Zip Code

Phone Number
Fax Number
E-mail
Are you a U.S. Citizen? yes  no
Is this a U.S. owned Organization? yes  no
Do you represent a Foreign Government? yes  no
PART II. REGISTRATION 
(GOMACTech is an Export-Controlled event that requires proof of U.S. Citizens or legal U.S. Permanent Resident status. Additionally, a signed Non-Disclosure Statement will be required.)
$500 GOMACTech-12 Conference Registration (includes CD ROM Digest) ($550 after 9 March 2012)
$250 One Day Registration (includes CD ROM Digest)
Tuesday Wednesday Thursday
$200 Student (Full Time) Registration (includes CD ROM Digest)
$20 Tutorial 1 (Monday 8:30 AM - 5 PM): Trusted Supplier Industry Day (includes lunch)
No Charge Tutorial 2 (Monday, 1 - 5 PM): Advanced Electronics Community of Interest
No Charge Tutorial 3 (Monday, 1 - 5 PM): EW
Wednesday Evening Dinner/Event/ Mystere Cirque du Soleil
QTY   Adult @ $25
QTY   Child(ren) (12&under) @ $15
$40 Additional GOMACTech-12 CD ROM Digest
PART III. PAYMENT INFORMATION
CREDIT CARD:  

VISA MasterCard AMEX Diner's Club

Card Number: Expiration Date (mm/yyyy):
  /
Questions or cancellations: Contact Glenys Natera at (800) 350-0111; fax: (212) 460-5460; [email protected]