Perspectives in Mathematical and Theoretical Physics Imperial College, 10 and 11 March 2006 Registration form REGISTRATION WILL REMAIN OPEN AS LONG AS THERE IS SPACE AVAILABLE If you cannot use this electronic form, please contact the local organiser and we will arrange an alternative. Section 1 Personal Details Last Name First Name I would like to attend on: Friday Saturday Friday and Saturday Title IoP Status (e.g. non-member, member, affiliate, fellow, etc) Email Institution If you are currently employed by or a student at a university or other higher education institution, please enter this here, together with your status (undergraduate, postgraduate, postdoc, etc) Address Postcode Telephone Special requirements Please specify any special requirements you think we should know about Section 2 Financial Position I would like help with travel and or accommodation costs REGISTRATION WILL REMAIN OPEN AS LONG AS THERE IS SPACE AVAILABLE