REGISTRATION FORM EUROSYMPOSIUM GALILEO 2001

Application will not accepted later than February 3rd, 2001

REGISTRANT IDENTIFICATION

Name:

Surname:
Age:
Country of Citizenship: 
Professional Status:

University / Institution:

Postal Adress:
Postal Code
City
Country:
Telephone:
FAX: 
E-mail:
ACCOMPANYING PERSONS
 
Name:
Surname:
Fee: A B 
Name:
Surname:
Fee: A B 
Name:
Surname:
Fee: A B 

 
Registrations Before December 30th After December 30th
Registrants Euros Euros
Accompanying persons (fee A)
x   persons		 Euros Euros
Accompanying 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:

FUNDACION CANARIA OROTAVA DE HISTORIA DE LA CIENCIA

Bank: CajaCanarias

Bank address: C/Inocencio García Feo, 3., CP 38200 La Orotava, Tenerife, Spain

Account number: 2065 0026 22 3000113778

Please, check your data before sending