17th INTERNATIONAL WORKSHOP ON RETROVIRAL PATHOGENESIS November1-5, 2005 Palais du Grand Large Saint-Malo - France Registration Form Full Name:_________________________ Organization/Affiliation:______________ Address:___________________________ __________________________________ City:______________________________ State and Zipcode____________________ Country: ___________________________ Phone:_____________________________ Fax: ______________________________ email: _____________________________ Please indicate if you are submitting an abstract : ABSTRACT : YES ❒ NO ❒ ORAL : ❒ POSTER : ❒ (Decision by the Scientific Committee) See instructions for Abstracts on the meeting WEB site (http://rvw17.free.fr) Payment method : Bank fees will be charged to sender. Checks: Please contact Annick.Perbal at: [email protected] Credit cards : Master Card : ❒ VISA : ❒ (sorry no other card accepted) Card Number:____________________ Expiration date: __________________ Cardholder:______________________ Total amount to be charged : (see below if additional nights or category change): ________________________________ Signature:________________________

Return registration form by fax to: B. Perbal : (33) 1 44 27 60 43 Registration fees package (750 Euros) must be received with registration and no later than August 15, 2004. The registration package includes admittance to scientific sessions, coffee breaks, all meals (except one diner), coktail and banquet, 5 nights accomodation in a two-star hotel on the basis of a twin room (B&B) shared with another registrant. An additional 100 Euros fee will be charged for late payment. Spouse/accompanying person fee: 550 Euros. Fees for accompanying person include meals and lodging but DO NOT include admittance to the sessions and coffee breaks. For additional nights and Change of Hotel category: Please contact Annick Perbal at [email protected] before returning this form Cancellation: The organisers reserves the right to cancel this workshop for any reason whatsoever. In the event of a cancellation, the full registration fees will be returned to the registrant. Refund Policy: Cancellation must be sent to B. Perbal by fax (33 1 44 27 60 43) prior to september 15, 2005. No refund will be granted after that date. Transfert to another person will not be permitted. A nominal fee of 50 Euros will be charged for processing.