Herewith, I register ___________ person/s for the Symposium

Option A Option B

Symposium only (31 May, 1-2 June), member Symposium only (31 May, 1-2 June) non-member

Name:____________________________ First name :____________________________

Organization:______________________________________________________________________

Street: ___________________________________________________________________________

Postal or Zip code:_________________________ Town:_________________________________

Country: ___________________________ Phone: ________________________________

Double bed room: Yes: No:

Payment:

Total :_____________ in US$ or CAN $ of Option A or Option B

Check or Money Order: Visa: Master Card:

Credit card number:

Expiration date:

Signature: ___________________________________________________________________