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