Registration Form for

Superstripes 2012
from July 11(expected arrival)
to July 17 (expected departure)

to be sent by e_mail to: conf.stripes@roma1.infn.it coping and and pasting the followings:

 __________________________

I intend to partecipate in the Stripes 2012 Conference.

   - My family name:
   - My first name (and initials):
   - My affiliation:
   - My address:
   - My e-mail address:
   - My telephone number
   - My fax:
   - Age:
   - Nationality:

- Select the 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:
   (Select one of the followings) , ,

- I will arrive on:  ..............(11 July Expected Arrival),

- I will leave on: ................ ( 17 July Expected Departure)

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

  12 July, 13 July ,14 July, 15 July, 16 July

- Flight details are the followings: _________________________

_________

Registration at Superstripes2012 for

Surname      : _____________________
Name            : _____________________

I have made the bank transfer

on (date): _____________________, amount: _____________________

Through the bank:
Bank Name    : _____________________
Bank address: _____________________