REGISTRATION FORM

Eurisol Topical and Town Meetings

Instituto Superior Técnico, Universidade Técnica de Lisboa
October, 15th-19th, 2012
IF YOU WISH TO PARTICIPATE PLEASE FILL IN AND RETURN THE FORM BELOW.

If you have problems filling or sending the form, please send the information by fax (+351 218419143) or by email to the secretariat.

REGISTRATION FOR TOWN MEETING:

REGISTRATION FOR TOPICAL MEETING:

NAME:

TITLE:

AFFILIATION:

ADDRESS FOR CORRESPONDENCE:

E-mail ADDRESS:

PHONE:

FAX:

ARE YOU INTERESTED IN PRESENTING AN ORAL CONTRIBUTION TO THE TOPICAL MEETING?

ARE YOU INTERESTED IN PRESENTING A POSTER TO THE TOPICAL MEETING?

ARE YOU INTERESTED IN PRESENTING A POSTER TO THE TOWN MEETING?

IF YES, PLEASE INDICATE THE PRELIMINARY TITLE AND SHORT ABSTRACT:

WILL YOU PARTICIPATE IN THE CONFERENCE DINNER (Wednesday, 17th October)?:

I AM A STUDENT(OR POST DOC) AND WOULD LIKE TO APPLY FOR FINANCIAL SUPPORT: