Liquid-Liquid Two-Phase Flow and Transport Phenomena, November 1997
REGISTRATION AND ROOM RESERVATION
| Family Name:____________________ | <![CDATA[ ]]> | Other Names:____________________
| | Affiliation and Address: | _____________________________________________
_____________________________________________
_____________________________________________
| | Tel:___________________ Fax:___________________ E-Mail:___________________________
|
[ ] Accompanied by Spouse and ____ children aged _____
Room Request:____ nights from: ___ / ___ /1997 to: ___ / ___ /1997
[ ] Single room [ ] Double room [ ] Triple room
[ ] Shared by family [ ] Shared by another participant
Full name of the other participant if you have a preference:___________________________________
Date:____________________
| Registration fee($US 350 or $US 400 or $US 100) | $______
| | Accommodation deposit($US 100) | $______
| | Total | $______
|
[ ] I enclose a bank check payable to Faruk Arinç; or
[ ] I enclose a copy of the bank transfer document; or
[ ] please charge my credit card for the above total amount
CREDIT CARD PAYMENT
Please charge ______ US Dollars to my [ ] Visa [ ] MasterCard [ ] Eurocard
Account Number: _________________________
Expiry Date: ____________________________
Signature: _________________________ Date: _________________________
Name as shown on Credit Card: ___________________________________
(This form is to be printed, completed, signed and sent to ICHMT Secretariat by
either fax or regular airmail, but not by e-mail as signature is not valid)
|
