SCGAS Registration Form

Registration for the 24th Southern California Geometric Analysis Seminar, February 11-12, 2017.

Please register before January 20, 2017 if requesting support. Priority will be given to those requesting support before January 6, 2017.

Fields in bold are required.

First Name:
Last Name:

Email:
Phone:

Institution:
Address (at least two lines):

Position:	Faculty Postdoc Graduate Student Other

Attending Banquet?	Yes No

Requesting Support?	Yes No

If requesting financial support, please fill out the following:

(1) Amount of support requested:

(2) Year of PhD (or for graduate student, please write down the expected year of your PhD and your faculty adviser):

(3) Gender: Male Female

(4) Under-represented minority? Yes No

(5) Any additional comments:

Notes:

There will be a nominal registration fee of $20, payable in cash at the conference.

(Problems using this registration form? Please email scgas@math.ucsd.edu.)