REGISTRATION FORM (if posted please type or use BLOCK LETTERS) I. Last name and title (e.g. Prof., Dr, ...): ..................... First name(s): ................................................. Affiliation:.................................................... Postal address: ................................................ Street: ................................................ Town with postal code: ................................. Country: ............................................... Phone: ........................................Fax: ............ E-mail: ........................................................ Nationality: ................................................... Number of accompanying persons: ................................ II. Contribution:Y/N If yes, please give title: ............................. Panel discussion contribution: Y/N If yes, please give title: ............................. I would like to display a poster: Y/N III. Payment: Prepayment by bank money transfer (please fax or mail a copy of receipt): Y/N Conference fee: ................................. Accommodation: ................................. Accompanying person: ................................. Total:.................................. I will pay the conference fee upon the arrival: Y/N IV. Accommodation preferences: HOTEL VERA single/double date of arrival: ............................. date of departure: ........................... no of nights: ................................ HOTEL GROMADA single/double date of arrival: ............................. date of departure: ........................... no of nights: ................................ please indicate time of your arrival if very late HOSTEL PAN single/double date of arrival: ............................. date od departure: ........................... no of nights: ................................ HOSTEL HERA single/double date of arrival:.............................. date of departure: ........................... no of nights: ................................ I am willing to share room Y/N (if yes please indicate roommate's name if preferred) Special requests: