REGISTRATION FORM PARTICIPANTS

Surname__________________________ Name____________________________

Address___________________________________________________ Nr._________

Zip code___________City_______________________Country_____________________

Institute/Hospital/University__________________________________________________

Tel. Home_________________________Tel. Inst./Hosp/Univ.______________________

Tel. mobile____________________________Fax________________________________

METHODS OF PAYMENT

Credit card: __ Eurocard/Mastercard: __ VISA

Credit card details: Please print names and numbers clearly.

Credit card number __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Credit card owner ________________________________Date of Birth ......................

Expiry date: __ __ / __ __ __ __ Signature:……..…………………………………………

All payments by credit card must be sent by fax or post

__ Eurocheque in Euro payable to I.M.C. srl

I am sending cheque n.__________________________ of Lit.___________________

Bank________________________________________________________addressed to IMC srl

IMC will address the invoice to: ______________________________________________

Address_________________________________________________________________

Zip code_____________________________City_________________________________

Country___________________________ Fiscal Code – VAT:______________________

This form is valid only if accompanied by the total amount of the services requested.

In accordance with rule 675/96 of the Italian law, the use of the above data is allowed.

Date Signature: ................................................................

To send to:

IMC srl

Viale Trieste 93

09123 Cagliari

Tel. +39 070 273470 Fax. +39 070 273306

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Last updated on: 10. May 2000 by A.Bischoff