Last Name: __________________________________________
First Name: __________________________________ Sex: _____
Affiliation: _____________________________________________________________________________________________________________
Address: _____________________________________________________________________________________________________________
Phone: _____________________________ Fax: _________
____________ E-mail: ___________________________________________________
I plan to attend also IWIN'2001
YES [ ] NO [ ]
Vegetarian: YES [ ]
NO [ ]
Student (an official certificate will be asked):
YES [ ] NO [ ]
Accompanying person
YES [ ] NO [ ] (please
print, fill and fax the form
for accompanying person)
Desired partner for room sharing (if student): _____________________________
Expected arrival:_____________________
Expected departure:_____________________
| NORMAL FEES | Early registration (before May 15, 2000) | Late registration |
| SIROCCO 2001 | (50.000 PTA - 300 EURO) | (60.000 PTA - 360 EURO) |
| SIROCCO'01 and IWIN '01 | (80.000 PTA - 480 EURO) | (90.000 PTA - 540 EURO) |
| STUDENT FEES | Early registration (before May 15, 2000) | Late registration |
| SIROCCO 2001 | (40.000 PTA - 240 EURO) | (45.000 PTA - 270 EURO) |
| SIROCCO '01 and IWIN 2001 | (65.000 PTA - 390 EURO) | (70.000 PTA - 420 EURO) |
Form of payment CASH
(on site only using PTA) [ ]
CREDIT CARD [ ] BANK
TRANSFER [ ]
Information for bank transfer paymen t:
Bank: La Caixa, Trias Giro 11-13, 08034 Barcelona,
Spain
Name Account: SIROCCO2001
Swift Code: CAIXESBB
International Bank Account Number: 2100-0655-78-0200251698
For credit card payment, you *must* provide the following
credit card information, now:
Visa: [ ]
Master: [ ]
Credit Card No.: __ __ __ __ __ __ __ __ __ __ __ __ __
__ __ __
Expiration Date (mm/yy): __ __ / __ __
Name of Card Holder: (use exact spelling)____________________________________________
Please sign :