Please type or print details in block letters and return with payment to :
Armel Le Bail
Université du Maine, Laboratoire
des Fluorures
Avenue O. Messiaen
72085 Le Mans Cedex 9
France
Tel :- +33 2 43 83 33 47 Fax:- +33 2 43 83 35 06
PERSONAL DETAILS
Family Name .............. Title ( Prof./Dr/Mr/Mrs/Ms/Other ) .
First Name
Address for Correspondence
Institution Department
Address .. . ..
.. . .
City .. Post / Zip Code .. ... . Country . ..
Telephone . Fax ..
E-mail .. .
REGISTRATION FEES - Students in
a developing countries
may ask for a discount - (in Euros) :
Full registration | 1000 Euros |
Student Registration (see below) | 500 Euros |
Students - Please have your Supervisor, or Department Head, sign here as proof of Student Status.
Name .. ...................... ........... .. Signature . .......................
Institution .......................... ..........................
Payment can only be made by cheque
or Bankers draft in Euros payable to Comptable de L'Université
du Maine', Trésorerie Générale 10071 72000 00003000179
52 :
Total | aaaaaaaEuros Eurosa |
Cancellation of the SDPD Course/Alteration of the SDPD
Course
It is a condition of this booking that the SDPD Course
organizers have the right for any reason beyond their control to alter
or cancel, without prior notice, the Course or any of the arrangements,
timetables, plans or other items relating directly or indirectly to the
Course and that the SDPD Course organizers shall not be liable for any
loss, damage, expenditure or any inconvenience caused as a result of such
alteration or cancellation and in the event of cancellation of the Course
the pre-paid registration fees will be returned in full.
Signature .............................................. Date ..........................
Complementary indications for the Université du Maine archives
:
Date of birth :
Birthplace :
Nationality :
Last diploma (date, name, place, University) :
Current occupation :
Personal address :
If possible, send an identity photograph as a .jpg attached file.