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Name:

Department/Institution:

Email:

Phone:

I plan to attend (check one):
( ) the statistical mechanics meeting in Canberra
( ) the mathematical physics workshop in Kioloa
( ) both the Canberra and Kioloa events

I would like to give a talk entitled:

[Participants may submit two titles if they wish to speak at both events]

I would like to attend the stat mech dinner on Monday night: YES/NO

ACCOMMODATION in Canberra (check one):

( ) Please reserve accommodation for me at Burgmann College
    bed and breakfast, shared facilities $75 per night
    Arrive:
    Depart:
( ) Please reserve accommodation for me at University House
    $133 per night including breakfast
    Arrive:
    Depart:
( ) I will make my own accommodation arrangements
( ) I understand that the organizers have already taken care
    of my accommodation arrangements

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