REGISTRATION FORM
Fifth International Conference on Finite Fields and Applications
Augsburg, August 2 - 6, 1999
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PERSONAL DATA

Title: __________________________
Status: __________________________
Surname: __________________________                               
Given name: __________________________
 
Affiliation: __________________________
Mailing Address:__________________________
City:  __________________________
Province/State: __________________________
Postal Code/ZIP: __________________________
Country: __________________________

Office Telephone: __________________________
Home Telephone: __________________________
Fax: __________________________
E-mail address: __________________________

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Do you intend to present a paper:   YES__________   NO__________

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FEES:                     

Registration fee                              DM _____________
Surcharge for late registration:              DM _____________
  additional tickets for Banquet at DM 70 :   DM _____________
  additional tickets for Recital at DM 20 :   DM _____________ 
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Total  Amount                             :   DM _____________