5th Franz Volhard Symposium

Registration Form

Susanne Meißmer
Conference Secretariat
5th Franz Volhard Symposium
Postfach 10 37 39	Fax 49/211/789715
D-40028 Düsseldorf	E-mail: [email protected]

Please note:

The number of participants is restricted to 100. Early application ensures participation.
First come - first serve!

Last Name	.....................................................................................................................
First Name(s)	....................................................................................................................
Institute	....................................................................................................................
Department	....................................................................................................................
Street	....................................................................................................................
Zip code / City	....................................................................................................................
Country	....................................................................................................................
Phone	....................................................................................................................
Fax	....................................................................................................................
E-mail	....................................................................................................................

Registration Fee

includes scientific program, accomodation from Thurday to Sunday (three nights), breakfast, coffee breaks, lunches, conference dinners on Thursday, Friday and Saturday nights, shuttle busses from the airpotz/station to the PANNONIA Hotel Döllnsee

		Before July 1, 1998	After July 1, 1998
O	Full registration	DEM 800.00	DEM 900.00
O	Students *	DEM 200.00	DEM 250.00
O	One-day registration **		DEM 150.00
	Please indicate the date(s) of your participation:	O Thursday O Friday O Saturday
O	One-day registration for students */**		DEM 50.00
	Please indicate the date(s) of your participation:	O Thursday O Friday O Saturday

* proof required
** without accomodation, breakfast, and shuttle arrangement

Payment

Payments will be refunded if a written cancellation is received before July 1, 1998, or if submitted abstract has not been accepted for publication. PAYSMENTS (payable to "5th Franz-Volhard-Symposium") must settle all bank handling charges in advance!.

O Cheque (e.g. Eurocheque)	All payments must be in Deutsch Marks!
O International Money Order
	Account Name: Franz-Volhard-Klinik
	Bank Name: Berliner Sparkasse
	Bank Code: 100 500 00
	Account No. 20 5000 5515
	Account Code: 5th Franz-Volhard-Symposium and participant's name !!!
O By Credit Card
	O VISA Card	O Master/EuroCard
	Cardholder's name:
	Card No.:
	Expiry Date:
	Cardholder's signature:
O Cash (on-site registration)

Date ........................................................................................................................................

Signature ...................................................................................................................................

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