Registration FORM ITQW 2011, 11-17 September 2011
Le Dune Resort & SPA – Località Li Junchi, Badesi Mare (OT)
We kindly ask you to fill out the form with all the information required and send it back via to
itqw2011@sns.it
Participant information
Name
___________________ Surname
___________________
Institution
___________________ Address
___________________
City
___________________ Country
___________________
Birth Date
___________________ Birth Place
___________________
Email
___________________ Mobile number ___________________
Phone
Number
___________________ Fax
___________________
Registration fees (including Monday to Friday coffee breaks, conference dinner and
excursion):
Until February 28th
2011
Regular
Students
Accompanying
person
□ 250 Euros
□ 150 Euros
□ 100 Euros
Until June 30th 2011
On site
□ 400 Euros
□ 250 Euros
□ 100 Euros
□ 500 Euros
□ 350 Euros
□ 100 Euros
Signature for acceptance
________________________________
1
Payment via bank transfer
Please mention: "Registrazione ITQW 2011"
NAME of the BANK ACCOUNT RESPONSIBLE: DELPHINA S.R.L.
BANK: BANCA DI CREDITO SARDO AG. DI ARZACHENA
ADDRESS: V.LE COSTA SMERALDA
IBAN code: IT 91N 0305984901100000001197
BIC code : BCITIT3C
Credit Card Details
Card Holder Name and Surname
___________________
Birth Date
___________________
Issue date
___________________
Expiration date
___________________
Card Number
___________________
I authorize the credit card payment of the amount ……………………
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