QT2005
ECME8
International Conference
Quantum Transport 2005
8th European Conference on
Molecular Electronics
Bologna, Italy
3 July – 5 July, 2005
Bologna, Italy
29 June – 2 July, 2005
JOINT REGISTRATION FORM
Please complete and fax this form to:
ECME8/QT2005 Secretariat
Attn: Mrs Maria Teresa Tibaldi
Fax n. +39 051 652 73 58
Last Name:
Title:
First Name:
Middle Initial:
Affiliation:
Address:
Zip Code:
City:
Country:
Phone:
Fax:
(included country and area code)
(included country and area code)
e-mail:
Name of Accompanying Person(s) (if any):
Joint Conference fee before May 25
Regular € 900
Early Stage Researcher € 650
Joint Conference fee after May 25
Regular € 1075
Early Stage Researcher € 825
Joint Conference fee on site
Regular € 1090
Early Stage Researcher € 870
n._______ copy/copies of QT 2005 Proceedings (€ 50 each)
Total due
€
Method of payment
Bank transfer
Unicredit Banca – Agenzia Bologna Gagarin
Via Gagarin, 13
40129 Bologna (Italy)
Account: 000010407431
CIN: M ABI: 02008
CAB: 02463
IBAN: IT43 M 02008 02463 000010407431
Copy of the bank trasfer should be attached to this registration form
Credit card
Visa
Eurocard/Mastercard
Name (as it appears on Credit Card)
Card number
Exp. date
/
I read the Cancellation Policy and approve the planned processing of personal data as described in “Registration”.
Date
Signature