R E G I S T R A T I O N F O R M
| Family name: ...................................................... First name: ................................ Title: ........ Institution: ........................................................................................................................ Department:....................................................................................................................... Address:........................................................................................................................... Postal code: .................... City:............................................ State:........................................ Ph.: ......................................... Fax: .................................... e-mail:...................................
Title of paper: ................................................................................................................. .................................................................................................................. Please insert the right amount in the end column and complete the total payment due:
PAYMENT BY 1. Credit card: Cardholder name:.......................................................... Birth date: _ _/_ _/_ _
Expiration date: _ _/_ _/_ _ Authorised signature: _____________________________
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