Surveillance 6 - October 25-26, 2011

( * ) Required field

Participant Information (1)

Title *: MrMrsDrProf

First Name *: Name *:

Nationality *: Position *:

Company/Organization *:

Address *:

Postal Code : City/State *:

Country *: E-mail *:

Phone (incl. country & city codes) : Fax (incl. country & city codes) :

Mobil Phone :

Billing Address

Same as above

Company/Organization *:

Address *:

Postal Code *: City/State *:

Country *: E-mail :

Phone (incl. country & city codes) : Fax (incl. country & city codes) :

Registration fees

* Tick category and fill in the amount to be paid.
* To qualify for the fees below, every registrant shall provide proof of status on the registration form.

	Before 15July 2011	After July 15 2011	On site
Research or Engineers ( Included congress diner)	EUR 400	EUR 500	EUR 500
Students	EUR 200	EUR 250	EUR 250
Extra fee for Congress dinner	EUR 30	EUR 30	EUR 30
Accompanying persons	EUR 80	EUR 80	EUR 80
Extra fee for Congress dinner	EUR 50	EUR 50	EUR 50

Research or Engineers Students Guest Accompanying person (Only one)

Attendance to the meals:

Lunch Oct. 25 Lunch Oct. 26
Congress diner Oct. 25 Accompying person (congress dinner Oct. 25 )

Without pork
Vegetarian diet

Total ( TTC ) : Euros

Payment options

Payment must be made in advance and are payable to: UTEAM.
Please make sure that you indicate "Surveillance6" and the registrant's name on all payments (eg: Surveillance6 registration fee for Dr. Stan Smith).
Payments should be made in Euros.
Order forms have to be made out to:

• UTEAM
• Colloque Surveillance 6
• 66 Avenue de Landshut
• Centre de transfert
• 60200 COMPIEGNE - FRANCE

Credit card ( Only MasterCard, Visa and CB will be accepted. On-line registration is now opened )

Bank transfer
  Payable in Euros to the following account:
  Bank : Crédit du Nord Compiègne Entreprise
  Code banque : 30076
  Code Guichet : 02626
  Num de compte : 10337100202
  Clé Rib : 44
  IBAN : FR76 3007 6026 2610 3371 0020 244
  BIC : NORDFRPP
  SIRET : 34230024100029 - Code APE : 8299Z

Check (only in Euros) to UTEAM
Guest (FREE)

CANCELLATION

- Registration All cancellations and changes must be sent to UTeam in writing (fax, letter or email).
For cancellations prior to 31 July 2011, fees will be refunded less 70 Euros (for administrative costs).
After this date, no refund is possible.
A handling fee of 30 Euros per registration will be charged for any modification after 1st August 2011


- Congress Dinner & City Tour
Cancellations can be made free of charge until 1st October 2011
After this date, no refund is possible.

This information is intended for the organizers UTeam or SFM in the purpose of setting down the list of the participants.
You may oppose to the publication of your email address in the list of participants by ticking here
You have a right of access and modification by applying to Uteam until 30/10/11 and afterwards to the SFM

Please type or write clearly in block letters and check boxes where appropriate and fax, post or email to:

• UTEAM
• Colloque Surveillance 6
• 66 Avenue de Landshut
• Centre de transfert
• 60200 COMPIEGNE - FRANCE
• RCS Compiègne 342300241
• Tel: + 33 3 44 23 45 30
• Fax: + 33 3 44 76 86 71
• Email: christine.sellier@utc.fr

Please provide information as you wish it to appear on your badge and in the list of participants (1).
"If these informations (First Name . Name . Company and Country) are not correct for establish the badge, please send an email."
Each participant should complete one copy of this registration form.
Please complete using a typewriter or block letters. Do not forget to make a copy for your own records.