DIMACS Workshop Registration Form

Workshop on Design for Values:

Ethical, Social and Political Dimensions of Information Technology

February 28-March 1, 1998

Please register by filling out the following blanks.

When finished and you have checked the correctness of information, press the "send" button at the bottom of the form.

Attendance is limited to available space; please register early.

       

  Dates you plan to Attend: 

           Your First Name: 
          Your Middle Name: 
            Your last Name: 

             Your Position:   (Please select best choice with button.)  


Your Postal Address: (This information will be used for nametags & mailing lists)
      Name of organization: 
                            (University or Company Name)


         Organization Type:   (Please select best choice with button.) 
                Department: 
            Street Address: 
     City, State, Zip Code: 
                   Country: 

                     Phone:  
                       Fax: 
                    E-Mail: 
              Web page URL:

Comments: (i.e. dietary restrictions)

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