Registration Form s22

SADA 2007

For Conference Organisation REGISTRATION FORM Committee use only BI:

SADA’07 26 FEBRUARY – 02 MARCH 2007 COTONOU - BENIN

Fill in this registration form and return it before February 20, 2007 either:

 by postal mail to: Colloque SADA – Laboratoire de Mathématique Appliquées de Pau Bâtiment IPRA Université de Pau et Pays de l’Adour Avenue de l’Université – BP 576 64012 Pau  by fax : +33 (0)5.59.40.75.55  by e-mail : [email protected]

Mr. Mrs Miss Family name: First name: Title: (researcher, teacher, student, non-academic)

Name of laboratory or company (attach purchase order if your organization pays for you):

Professional address: Financial department (E-mail): Postal code: City: Country: E-mail: Phone (incl. Country code):

Participating as: Speaker Delegate Registration is mandatory to gain access to conference and must be done before conference opens.

REGISTRATION FEES Family name: First name: Before Registration fees include: Feb,20,2007 Full rate 140 € Abstract Student 40 € Lunches Coffee break Gala dinner Company 240 € Accompanying person € Total registration payment

CONDITIONS OF PAYMENT (tick box) Payment in Euros only to be sent to:

 E-mail: [email protected]  fax : +33 (0)5.59.40.75.55 1 – Bank card Secured Transaction * (VISA, EUROCARD, MASTERCARD ONLY) * Certified SSL Protocol

2 – Bank transfer (attach copy of bank transfer sheet): Account holder: « Agent Comptable Secondaire du CNRS » 10071-33000-00001000242/18 IBAN: FR76 1007 1330 0000 0010 0024 218 – BIC/SWIFT: BDFEFRPPXXX Bank address: Trésor Public – Trésorerie Générale – 24, rue François de Sourdis BP 908 - 33060 Bordeaux Cedex

3 – Bank cheque to be made out to « Agent Comptable Secondaire du CNRS » and to be sent to:

4 – If your organization pays for you: attach purchase order bearing the following information: «Registration fees for Mr. or Mrs X… to the conference « ………………………..», made out to: « Agent Comptable Secondaire CNRS ». Purchase order n°: Invoice needed: yes no CNRS Siret n°: 180 089 013 02458 VAT n°: FR40 180 089 013

Your receipt will be given to you on the day of your arrival on site.