FuDiCoIII Registration Form

FuDiCoIII
Registration Form

Please complete the form by filling out all fields and then click the "Submit" button below. Fields marked with an * are obligatory.

First Name: *

Last Name: *

Sex:

Male	Female

Affiliation: *

Street Address:

City/State:

Postal Code:

Country:

E-mail address: *
Confirm e-mail: *

Arrival Date: *

Departure Date: *

I intend to give a talk:

Yes	No

If yes, title of talk:

You can choose either a single-room or a double-room for your accommodation with respective regsitration fees of 500 and 420 Euro. In case you opt for a double-room, you can indicate the name of your roommate if you know it. Otherwise, the organizers will contact you regarding a roommate.

Accompanying person fee is 75 Euro per day (300 Euro for 4 days), covering everything, including the night excursion.

I will be accompanied by:

Room type:

Single	Double

Name of roommate:

Amount to be paid:

Method of payment (select one):

Credit Card (Visa, Master Card or American Express only)
Bank transfer to:

Banca Popolare dell'Emilia Romagna
Filiale di Bertinoro
Via Roma, 10
47032 Bertinoro (FC)
Italy

Beneficiary: Ce.U.B.
IBAN: IT 19 N 05387 67721 00000 1052782
SWIFT (BIC): BPMOIT22 XXX (for international bank transfers)

Please make sure that your name, address and "FuDiCoIII" appears on the bank transfer request.
Also, make sure you send a photocopy of the transfer form to:

Eleonora Campori (FuDiCoIII)
Via Frangipane, 6
47032 Bertinoro (FC)
Italy

Invoice of Payment: Italian law requires that an invoice be issued reflecting your payment. If you require an invoice to be issued to you personally, then make sure that you give your name and home address (not that of your institution). All fields are obligatory.
Invoice issued to: *
Address of above subject: *
Tax number (or equivalent) of above subject: *
(For Italian registrants, tax number is the "Codice Fiscale" or "Partita IVA")

Cancellations: There will be a 100 Euro fee applied to the cancellation of a registration. Substitutions okayed by the organziers may be made at any time without incurring penalties.

By clicking the "Submit" button, you are agreeing to the use of your personal information by CeUB for the sole purpose of handling your registration to the event in question. The information you have provided will not be communicated to any other parties. Should you wish to exercise your rights regarding the protection of personal data under Italian law, please contact CeUB in writing at: Via Frangipane 6, 47032 Bertinoro (FC) Italy.

Make sure you read and follow the instructions that appear on the next screen after clicking the "Submit" button.