ECP'97 Registration Form
Institution / Affiliation:
Address:
City:
Zip Code: Country:
Phone:
Fax: E-mail:
Registration Fees |
Amount (in French Francs) |
Early registration (2500 FF): |
|
Late registration, after September 12 (2700 FF) |
|
Additional banquet tickets (250 FF per ticket) |
|
Total amount |
|
Date: Signature
Method of Payment:
Credit Card (only CB, VISA, Master Card, Euro
Card)
Card type: | |
number | |
expiration date | |
amount | |
date | |
signature |
Bank transfer: I have remitted (amount):
FF on
(date)
through (your bank name) to the account of:ADERMIP
Bank Name | Banque Courtois |
Account Name | A.D.E.R.M.I.P. |
Domiciliation | Toulouse Remusat |
code banque | 10268 |
code guichet | 02504 |
account number | 12719500200 |
cle rib (key) | 49 |
I will pay with a credit card at the conference registration
desk
fill the form and fax it or mail it toSylvie Barrouquère
-ADERMIP - Z.I. Montaudran
3 Avenue Didier DAURAT - 31400 Toulouse (FRANCE)
Tel: (33) 5 62 47 49 89 / Fax: (33) 5 61 80 81 75