Registration Form for Stripes 11

to be sent by e_mail to: con.stripes@roma1.infn.it

 __________________________

I intend to partecipate in the Stripes 11 Conference.

   - My family name:
   - My first name (and initials):
   - My affiliation (for the conference badge):
   - My address:
   - My e-mail address:
   - My telephone number:
   - My fax:
   - Nationality:

Academic qualification,(present position):
 (  I am just starting, I am not even yet a PhD student.)
   (I am a PhD student.)
(   I am a postdoctoral fellow
 (  I am a faculty member and/or a senior researcher.)

- I will submit an abstract   for:
   ,

- I will arrive on:

- I will leave on:

-I will attend (Select the days you are going to attend):

   July (10, 11, 12, 13, 14,15 )

- Flight details are the followings:

I have registered by bank transfer on (date):
Bank Name:
Bank Address:
Amount: