REGISTRATION FORM

Name (Last, First)
Organization
Street Address
City
State
Country
Zip or Postal Code
Telephone
Fax
E-Mail Address

Fees (in Euros): 

Full package^*, including accommodation and meals (participant) Euro 480

Full package*, including accommodation and meals (accompanying person, sharing a double room with you) Euro 420

Indicate name of the person with whom you will be sharing your room

Registration only (accommodation, meals and field trip NOT included) Euro 100

          

Total

 

*Includes accommodation on June 2, 3, 4; all meals from dinner of June 2 to lunch of June 5; registration; field trip

.

                    Method of Payment

a) Credit Card
Type of Card     VISA MasterCard EuroCard
Here are the details of my credit card for immediate on-line registration:
   Name on Card (print)
   Number
01 02 03 04 05 06 07 08 09 10 11 12 2004 2005 2006 2007 2008 Expiration Date
01 02 03 04 05 06 07 08 09 10 11 12 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Birthdate (mandatory: month-day-year)
Signature (not needed for online registration):_____________________________

I will mail the details of my card with a printed and signed copy of this form

b) I want to register now and am sending a printed and signed copy of this form with details of my bank draft ___

If you do not register online, please fax or mail registration forms (including details of your credit card) to:
CESNUR
Via Confienza 19
10121 Torino, Italy
Fax: +39-011-541905

If you select option (b) please mail or fax forms to CESNUR, and send bank drafts to CESNUR PIEMONTE as follows
Name of bank: Deutsche Bank, Via Arcivescovado 7, 10121 Torino, Italy
Bank codes:
Account number: 33719
ABI: 3104
CAB: 01000