EuCheMs School on “ Synthesis and Characterization of Novel Nano-Sized Inorganic Materials” 17-22 June, 2012 Department of Chemistry, Campus Universitario, Bari Registration Form for PhD, Post Docs, or Industrial staff Please fill-in this form and send it back by e-mail to: materials.circc@uniba.it within March 31th, 2012 at latest Name ______________________ Surname ___________________ Male Female Date and place of birth ____________________________________________________ Academia Industry Academic Institution ____________________________________________________ Company ____________________________________________________ Registration fee Member of National Chemical Societies 500 €* half-board Non-Member of National Chemical Societies 550 €* half-board Industry 600 €* half-board *Accommodation in two-bed rooms Roommate Name____________________________________________ Supplement for the single room: 20 € per day per person: total_____ € Personal request:_________________________________________________________ Vegetarian Smoking room Total amount due: Yes Yes No No ____________________________________________________ Mode of Payment: * Bank Transfer to the Bank Account IBAN: IT09 T010 1004 0021 0000 0002 835 BIC/SWIFT: IBSPITNA NOWATECH Ass-School EuCheMs I will present a poster I will deliver a 5 min flash oral presentation Title: ……………………………………………………………………………… Authors: underline the name of the presenting author Institution: ___________________________________________________________________ Company: ___________________________________________________________________ Address: ___________________________________________________________________ I will arrive in Bari on June _________ at ________and leave on____________________________ at____ Participants are expected to arrive in Bari on June 17, 2012 and leave on June 22. Any extra day will be calculated at 68 € per day half board or 55 € per day bed and breakfast. Deadlines: April 5th- April 30th, 2012 March 1st- March 31th, 2012 June 17, 2012 Payment of fee Copy of abstract Copy of slides at the registration desk