Registration Form





First name:.........

Last name:..........

Address:.............

Nationality..........

Company/
Organization.......

PHONE
Home:................

Busines:.............

Fax:...................

E-mail:...............

ACCOMPANYING PERSON

1. Name.............
........................ age over 21 under 21 under 15

2. Name.............
........................ age over 21 under 21 under 15

3. Name.............
........................ age over 21 under 21 under 15

STATEMENT TO DELIVER A PAPER
I intend to deliver a paper at ICV in
Yes No

English. ...
French.....
German...
other language:

You may publish my intention to attend on the congress homepage:
Yes No

SPECIAL REQUIREMENTS:
Please indicate if you have any special requirements such as diet etc...

...........For your security please print this form and send it to:

PAYMENT - ICV 21 FIAV "VEXILOBAIRES 2005"

Dear Friends:

For those planning to attend ICV 21-Vexilobaires 2005, we are strongly recommending to make the payment for the registration fee using Western Union instead of a bank to bank transfer. The fee charges at both end are tremendously high.

On the other hand, Western Union moneygram is fast, secure and inexpensive. You l can do it over the phone and charge the amount to your credit card.

Made the moneygram to the order of Anibal Gotelli, a write to us with the moneygram number.

By return e-mail you will receive an acknowledgment of payment. Print that acknowledgment and take with you to be presented during the registration as proof of your payment.

Thank You.