The Liberty Bell Symposium -- Payment Form
This form can be used for both registration fees and/or
lodging and meals. Checks, money orders or cashiers checks should be made out to
Penn State Berks/The Liberty Bell Symposium
This payment form should be filled out and mailed with your payment to:
Professor Ali Alikhani, Director
The Liberty Bell Symposium
Department of Mathematics
Tulpehocken Road
Penn State Berks
Reading, PA 19610
USA
Contact Information
Name:
Mailing Address:
Day Telephone:
Night Telephone:
Fax Number:
e-mail:
Social Security Number
Registration Fees
-
Regular Registration (received prior to May 15) $150
-
Late Registration (after May 15) $175
(All but $10 is refundable if cancelled by June 15.)
Dormitory Lodging and Meals
-
Monday night-Friday night (inclusive) $225
-
Monday night-Saturday night (inclusive) $280
Your registration fee includes the use of conference facilities,
refreshments, a Thursday afternoon outing, and one ticket for
the traditional Friday evening banquet. If you wish to purchase a
ticket for your accompanying guest to join us for the outing on
Thursday and the banquet on Friday, the combined tickets are
available for $35 per person.
How many additional combined tickets will you need? _______
-
Personal Check (made out to Penn State Berks/The Liberty Bell Symposium)
-
Cashiers Check or Money Order (made out to Penn State Berks/The Liberty Bell Symposium)
-
Please contact Professor Alikhani directly at
alikhani@psu.edu
if you are required to pay with a credit card or if you have questions
concerning payment.
Payment together with a copy of this form may be sent to:
Professor Ali Alikhani,
Director
The Liberty Bell Symposium
Department of Mathematics
Tulpehocken Road
Penn State Berks
Reading, PA 19610
USA