Request for Visa Assistance (paper authors only!)

Please Print or Type all Information


Name: __________________________________________________________________

Email address: ___________________________________________________________

Conference Title: _________________________________________________________

Conference Dates: ________________________________________________________

Conference Location: ______________________________________________________

Are you an IEEE Member? Yes No If Yes, Your IEEE Member Number:_____________

Are you a speaker/presenter? Yes No

Name of session you are speaking/presenting: __________________________________

To what post office address should the letter be mailed?
Street: ___________________________________________________________
City: _____________________________________________________________
State/Province: ____________________________________________________
Postal Code _________________ Country: _____________________________

E-mail: ___________________________________________________________

Telephone:________________________________________________________
Fax:______________________________________________________



Please forward this form to:
(Shakeera Thomas: e-mail: shakeera@cs.sunysb.edu or fax: 631-632-1784)