IXth International Meeting on the Biology and Pathogenicity of Free

of Free-Living Amoebae. IXth International Meeting on the Biology and Pathogenicity of Free-Living Amoebae. REGISTRATION FORM. Please fax this form to :.
141KB taille 2 téléchargements 290 vues
IXth International Meeting IXth International Meeting on the Biology and Pathogenicity on theofBiology and Pathogenicity Free-Living Amoebae of Free-Living Amoebae REGISTRATION FORM DELEGATE REGISTRATION Please fax this form to : Check up Service : 33 (0) 1 48 77 08 63 Name (family name) MD. ❐

................................................................................................

PhD. ❐

Name of institution

Mr. ❐

Mrs. ❐

Miss ❐

First name ...................................................................................... Ms. ❐

..............................................................................................................................................................................................................................

Address .......................................................................................................................................................................................................................................................... Zip or Postal Code ................................................................................................ City ........................................................................................................... Country .......................................................................................................................... Fax ...................................................................................... E-mail I will be accompanied by ................................ persons

Telephone ......................................................................................................

.......................................................................................................................

❐ I intend to present a paper and will send you the full text before April 30th

FEES Delegate: 2500 FF (381.12 €)

Student: 1000 FF (152.45 €)

SOCIAL PROGRAMME ❐ I will attend happy hour on Sunday July 8 ❐ I will attend the gala dinner at the Musée J. André on Wednesday July 11 ❐ I will attend the sight seeing tour in the Marais and the cruise dinner July 13

PAYMENT 1. Registration fee FF or €

Total: ............................................................

2. Accompanying person for the gala dinner (…x 600 FF ) FF or € 3. Registration fee for tour in the Marais and cruise dinner (500 FF) FF or €

Total: ............................................................ Total: ............................................................

4. Accompanying person for tour in the Marais and cruise dinner (….x 500 FF) FF or €

Total: ............................................................

TOTAL AMOUNT (1+2+3+4) ...................................................................................................................................... ❐ Bank cheque in FF to Check Up Service ❐ Bank cheque in € to Check Up Service ❐ Credit card in FF Card holder name : .................................................................................. ❐ Visa

Date

❐ Eurocard Mastercard Card Number

................................................................................

Signature of the card holder

Expiry Date