Registration form
We kindly ask you to fill out the form with all the information required and send it back via to
miriam.vitiello@sns.it
Participant information
Name
___________________
Surname
___________________
Institution
___________________
Address
___________________
City
___________________
Country
___________________
Birth Date
___________________
Birth Place
___________________
Email
___________________
Mobile number
___________________
Fax
___________________
Phone Number ___________________
Registration fees
The conference registration for technical attendees includes:
scheduled airport shuttle transportation
participation to technical session;
industrial exhibition;
welcome reception (Sunday);
coffee breaks;
everyday lunches (Monday-Friday);
everyday dinners (Sunday- Wednesday);
conference banquet (Thursday);
excursion (Wednesday)
social events
Until May 1st 2014
Regular
Students
Accompanying person
□ 520 Euros
□ 390 Euros
Until July 10th 2014
On site
□ 560 Euros
□ 450 Euros
□ 600 Euros
□ 490 Euros
----------------------------
□ 400 Euros
(including airport transportation, everyday lunches, everyday dinners, excursion and conference banquet)
Signature for acceptance
________________________________
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□ Payment via bank transfer
Please mention: "Registrazione IQCLSW 2014"
Bank account details:
NAME of the BANK ACCOUNT RESPONSIBLE: Nordic Travel S.r.l. c/o
BANK: Banca Popolare di Milano ag. 347 Milano
swift code: BPMIITMM
iban: IT43 Y055 8401 6580 0000 0003012
□ Credit Card
(only VISA and MASTERCARD)
Card Holder Name and Surname
Email:
___________________
___________________
A link will be provided directly to you to proceed with payment
Signature (required) for acceptance
___________________
Please specify if you need a simple receipt with heading or an invoice (VAT number will be necessary).
Signature for acceptance
________________________________
2