| * Name: |
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| * First name: |
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| * Title: |
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| * Company/Organis.: |
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| * Mailing Address: |
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| * City: |
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| * ZIP Code: |
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| * Country: |
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| * Tel. Number: |
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| FAX number: |
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| * E-mail address: |
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* VAT No
(Organization payment)
OR Fiscal Code (Private/personal payment)
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| Are you an Invited Lecturer? |
Yes |
No |
| Full Participant: |
Yes |
No |
Student participant:
(incl. PhD students)
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Yes
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No |
| I would like to attend the Symposium: |
Yes |
No |
| I would like to submit contribution: |
Lecture
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Poster |
Title |
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| Upload your abstract |
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| A free babysitting service may be available during the event, p lease fill in the following part carefully: |
| No of children: |
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| Age(s) of child(ren): |
(comma separated) |
| I will attend: |
Lunch on May,29th |
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Dinner on May,29th |
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Lunch on May,30th |
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Dinner on May,30th |
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Lunch on May,31st |
| *Registration Fee |
| After April 15th, 2006 |
Researcher
€ 375
(Italian VAT not applicable) |
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Student
€ 175
(Italian VAT not applicable)
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*Billing Address
Please read carefully before proceeding.
This is the address the relevant invoice should be ISSUED to. Please note, that in case of credit card payment the invoice obligatorily has to be issued to the cardholder. Example: You CANNOT use your personal credit card, if you want the invoice to be issued to your institution (or vice versa). Kindly keep in consideration this important point while compiling the following fields.
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*Billing Address |
Same as above |
New |
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* Payment type |
Bank transfer (starting from January 1 st, 2006) with reference to " 2 nd International Symposium on Nanostructured and functional polymer-based materials and composites” (NANOFUN-POLY) ", specifying the name of the participant, made payable to:
Consorzio INSTM
C/c 000009564584
ABI 03400 - CAB 02800 - IBAN IT 73 S 03400 02800 000009564584 - SWIFT TOSCIT3F200
Banca Toscana – Capogruppo di Firenze
Via del Corso, 6
I - 50122 Florence, Italy
Please send the total due amount free of any bank charges.
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Credit card (VISA, Mastercard).
For payment by Credit Card, please download and print the proper form (Authorisation for Credit Card Payment), fill it out clearly with all required information and then send it ONLY by FAX to:
Mr. Daniele Consigli
Consorzio INSTM
Fax no. +39-055-2480111 (reserved line)
IMPORTANT: The above mentioned form DOES NOT substitute the present Registration Form. Sending ONLY the form for the credit card payment DOES NOT complete your registration.
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ATTENTION! Your registration will be valid only with your acceptance of the conditions reported below:
With reference to the Italian law 675/96 we wish to inform you that your personal data will be used within the "2nd International Symposium on “Nanostructured and functional polymer-based materials
and composites” (NANOFUN-POLY)" institutional activity. We also wish to inform you that your personal data will be inserted in the participant list relevant to the present event.
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I herewith confirm that I agree that my submitted data concerning addresses, booking and methods of payment be electronically stored and processed in order to organize and manage this event. Furthermore, I accept that address and personal data are used for purposes connected to the event's management and will be published in the list of participants.
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