registration form - Dipartimento di Scienze Statistiche
Transcript
registration form - Dipartimento di Scienze Statistiche
First Name: Last Name: Nationality: Institution/Company: Address: Zip code, Town and State, Country: Your fax number: Your e-mail address: Your arrival date: Your departure date: Expected number of days: Registration fee: Event Select Fee Amount to pay Registration fee - payment before 30th of April 50 € 0 Registration fee - payment after 30th of April 70 € 0 Workshop dinner - accompanying persons; specify number 45 € 0 0 Sum Financial details. Dipartimento di Scienze Statistiche. Code Iban. Unicredit Banca spa. Agenzia di Piazza Aldrovandi n.12/a. 40126 Bologna ‐ IT16Y0200802457000002979851 Europe code IT16. code CIN Y. Code Abi 02008. Code Cab 02457. Number 000002979851 code BIC SWIFT:UNCRITB1PM7 (for overseas payments) Number of payment Date Payment reason Please, insert in the payment reason, the follow description: “Convegno Rimini 2009” ‐ Attention! This is an interactive form: after inserted the required information, save them with your name and send by e-mail to [email protected] ‐ Thank you