Registrant Information (Please print clearly) *INDICATES REQUIRED FIELDS THAT MUST BE COMPLETED

*Last/Family/Surname*First/Personal Name

*Company, University or Other Affiliation*Job Title

*Address P.O. Box / Mail Stop

*CityUS State/Canadian Province*Zip/Postal Code*Country

*Primary Contact NumberFax NumberMobile Phone

Emergency Contact NameContact Number

IEEE Membership Number*Email Address (for confirmation purposes)

If you have a disability and may require special accommodations in order to fully participate, please check the box below. You will be contacted by someone from our staff to discuss your specific needs. Please check the box if you have any special needs.

Please indicate your special need(s):____________

What is your reason for attending CogSIMA 2011?
(Please check all that apply)
Education
Network with others
Present at paper/poster/demo
Other ______/ Organizational Status:
(Check all that apply)
Industry
Government
Academia
Other: ______/ *How did you hear about CogSIMA?
IEEE CogSIMA 2011Web site
CFP Announcement
IEEE Communications Magazine
Colleague
Social Media
Other ______

All Authors must register by 1 January 2011.

At least one author of each accepted paper must register on/before 20December 2010 at the Member or Non-member rate. Student authors can register at the Student Member or Student NON-MEMBER rate. PLEASE NOTE: To be published in the IEEE CogSIMA 2011 Conference Proceedings and IEEE Xplore®, an author of an accepted paper is required to register for the conference and the paper must be presented at the conference. Registration fees must be paid in order to upload the final IEEE formatted, publication-ready version of the paper. Conference Proceedings and in IEEE Xplore®. Paper ID #: ______Number of pages:______

Registration Includes: Welcome Reception, CD-Rom Proceedings, Conference Banquet and coffee breaks.

Members of IEEE and the following ComSoc Sister Societies may register at the IEEE Member Rate (circle all applicable):
AICA AICT AIU CCIS CIC CIE CIEE CMAI CoE EWI EZS FITCE HTE IEICE-CS IEM IETE IIC ITU KICS LITKA MAEECE POPOV PTC REV SAIEE SBrT SCS SEE SEEI SR VDE

ATTENDEE REGISTERATION ON/BY 22 JanuaryAFTER 22 January

ComSoc MemberUS$550 US$650

IEEE/HFES Member1US$575 US$675

Non-Member2US$690 US$810

IEEE Life Member US$50 US$50
IEEE Student Member(FULL TIME STUDENTS ONLY)US$125 US$130

1. Includes complimentary IEEE ComSoc membership (digital delivery of IEEE Communications Magazine)
2. Includes complimentary affiliate ComSoc membership (digital delivery of IEEE Communications Magazine)

ADDITIONAL ITEMS

Qty ____ Banquet US$70 Qty ____Additional CD-ROM US$25 Qty ____ Overlength Paper Charge US$100 (7 pages included. Maximum of 3 additional pages)

VISA ASSISTANCE LETTERS:Non‐Authors (Speakers, Committee Members, and paid attendees) requiring visa assistance letters, or authors needing a hard copy of the letter must complete a Comsoc Visa Assistance Request ( Authors should go EDAS to retrieve their personalized visa assistance letters (soft copy in PDF format).

CANCELLATION POLICY:All refund/cancellation requests must be provided via email to (or in writing to the address at the bottom of the form) and received by 23 January 2011. No refunds will be provided after this date. Please note: author registrations are non‐refundable. There will be a US $100 administrative fee deducted from each refund.

Registration Total Additional ItemsTotal Remittance

$______$______$______

IEEE may use the information you provide us to contact you from time to time concerning similar IEEE conferences, technical products and services or to ask your opinions. If you do not want us to contact you please check here:

REGISTRATION PAYMENT

CHECK Issued in US Dollars (Payable to: IEEE CogSIMA 2011) Visa MasterCard American Express Discover

Card Number ______Expiration Date ______

Name on Card ______Authorized Signature ______

Mail/Fax/e‐mail Completed Registration Form & Payment To: IEEE/MCM: Becky Lynn, Registrar 445 Hoes Lane, Piscataway, New Jersey 08855 USA

Fax: +1 732 465 6447 E‐mail:

Non-discrimination: "IEEE is committed to the principle that all persons shall have equal access to programs, facilities, services, and employment without regard to personal characteristics not related to ability, performance, or qualifications as determined by IEEE policy and/or applicable laws. For more information on the IEEE policy visit