DIMACS Workshop Registration Form

DIMACS/MBI US - African BioMathematics Initiative: Workshop on Genetics and Disease Control
University of Cape Coast, Cape Coast, Ghana

August 8 - 12, 2011

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.

Registration fee of $300 will be collected in cash on site. Fees include lunch and breaks. To apply for a partial waiver of fees, please email request with explanation of reason for waiver and amount of waiver requested to Gene Fiorini (usai (at) dimacs.rutgers.edu).

Dates you plan to Attend:
Your First Name: Your Middle Name: Your last Name:
Your Position:

Your Postal Address: (This information will be used for nametags & mailing lists) Name of organization: (University or Company Name)
Organization Type:
Department: Street Address: City, State, Zip Code: Country:
Fax: E-Mail: Web page URL:
Comments: (i.e. dietary restrictions)

Please contact the organizer(s) directly if you would like to submit a paper or poster.

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