registration form

REGISTRATION FORM

http://research.iac.es/proyecto//galileo/inscrip/Form.html

Applications will not be accepted later than February 3rd, 2001

REGISTRANT IDENTIFICATION

Name:

Surname:

Age: Country of citizenships:

Profesional status:

University / Institution:

Postal Address:

Postal Code: City: Country:

Telephone: Fax:

E-mail:

ACCOMPANYING PERSONS

1. Name: Surname: Fee:    A     B

2. Name: Surname: Fee:    A     B

3. Name: Surname: Fee:    A     B

Registrations Before December 30th After December 30th

Registrants Euros Euros

Acompanying persons (fee A):
x________persons
Euros Euros

Acompanying persons (fee B):
x________persons
Euros Euros

TOTAL
Euros Euros

REGISTRATION PAYMENT CONDITIONS

Payment should be remitted as follows:

Bank transfer (in EUROS), free of any Bank charges, should be made to:

FUNDACIÓN CANARIA OROTAVA DE HISTORIA DE LA CIENCIA

Bank: CajaCanarias

Bank address: C/ Inocencio García Feo, 3. CP 38300 La Orotava (Tenerife). Spain

Account number: 2065 0026 22 3000113778

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Name:
Surname:
Age:		Country of citizenships:
Profesional status:
University / Institution:
Postal Address:
Postal Code:	City:		Country:
Telephone:		Fax:
E-mail:

1. Name:	Surname:	Fee: A B
2. Name:	Surname:	Fee: A B
3. Name:	Surname:	Fee: A B

Registrations	Before December 30th	After December 30th
Registrants	Euros	Euros
Acompanying persons (fee A): x________persons	Euros	Euros
Acompanying persons (fee B): x________persons	Euros	Euros
TOTAL	Euros	Euros