Registration Form

REGISTRATION FORM

IV Workshop on Non Equilibrium Phenomena
in
Supercooled Fluids, Glasses and Amorphous Materials

Pisa, Italy, September 17 - 22, 2006

Please send the form together with a copy of the receipt of the bank transfer
ONLY by FAX and before May 31th, 2006 to

Meridiana Events & Education SRL

Fax: +39 050 974148

Partecipants under 35 years: please enclose a photocopy of your identity card

Please print:

Dr: , Prof: , Mr: , Mrs:

Family Name

First Name

Accompanying Person Name

Affiliation

Address

City Zip Code

Country E-mail:

Phone Fax

Registration Fees*	Before 31 May 2006	After 31 May 2006 (after 5 September 2006 only on site registrations will be accepted)	N.	Total Amount
Active participants	375 Euro each	400 Euro each
Active participants under 35 years of age	285 Euro each	310 Euro each
Accompanying persons	120 Euro each	120 Euro each
		TOTAL PAYEMENT	Euro

* Including: welcome party, coffee breaks and snack lunches .

Cancellation Policy

Only written cancellations will be accepted.

Cancellations received before August 15, 2006: the total payment will be refunded less 50 Euro per participant as cancellation fee.

No cancellations will be refunded after August 15, 2006 .

PAYMENT OF THE FEE

The receipt of the payment will be acknowledged by Meridiana Events & Education srl by e-mail.

The registration will be finalised only after the payment of the fee.

Payments are accepted only by bank transfer.

All bank charges have to be covered by the payer.

Bank transfer details:

I remitted the amount of Euro

on (month/day/year)

through (bank name)

to the following account:

Bank: Monte dei Paschi di Siena, Filiale di Pisa, Lungarno Pacinotti 9, I-56100 Pisa, ITALY
(ABI: 01030, CAB: 14000, SWIFT (BIC): PASCITMMPIS, IBAN : IT 66 U01030 14000 000002113533 )

Account number: 21135. 33
Account holder: Comitato Organizzazione IV Workshop on Non Equilibrium Phenomena
IMPORTANT. When faxing the copy of your bank transfer, in order to avoid any possible difficulty, please specify the conference title and the name of the participant.

Date

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N.B. With reference to the italian law 675/96 please be informed that your personal data will be used by IV Workshop on Non Equilibrium Phenomena in Supercooled Fluids, Glasses and Amorphous Materials within its normal institutional activity. We also inform you that your personal data will be inserted in the list of participants relative to the present event.