Registration Form for IMA Mathematical Modeling in Industry

                         May 26 -- June 3, 2002

Please submit by Fax 612-626-7370 or by Email to ima-staff@ima.umn.edu

Name:_______________________________________

Institution:__________________________________________

Department Address: __________________________________

                    __________________________________

                    __________________________________

                    __________________________________

Email: _________________________

Phone: _________________________

Status:  grad _______ yr ________(1st, 2nd, etc)

         undergrad ________ yr _____(Junior or Senior)

Arrival date: ____________________  Departure date: _____________________

Citizenship (for visa purposes) _______________________


Brief Background:

  What is your career goal?



  What courses have you taken that may be relevant to the workshop
     participation?



  In the space provided, please state why you are interested in
     participating, what are your expectations.




  Please rank the industrial problems topics for this workshop in
    order of your preference, 1 being most preferable, 6 being least
    preferable.

	1.					2.
	3.					4.
	5.					6.	


Two letters of recommendations are required

       Recommender 1: _________________________

       Recommender 2: _________________________