Registration Form for Improve 2011

Registration form for IMProVe 2011

Please fill in and return this form to the following address

June 15th – 17th, 2011, Venice, Italy Registration form for IMProVe 2011

Recipient information

LIBRERIA INTERNAZIONALE CORTINA

DIVISIONE EVENTI

Attn. Ms. Donatella Beltramelli

e-mail:
Tel +39 049 656921 int. 4, Fax +39 049 8754728

Key dates registration

April 15th 2011

Early registration deadline (reduced fee)

April 30th 2011

Author registration deadline

June 15th – 17th, 2011, Venice, Italy Registration form for IMProVe 2011

Participant information

Type or print in capital letters

Mr. / Mrs.
First name
Last name
Organization/Company
Address / City
State/Province / Postal/Zip code
Country
Telephone number
(country, city and area codes)
Fax number
E-mail
Web

Registration fees

Fees per person (VAT included)

Participant / Before April 15th2011 / After April 15th2011 / After May 1st 2011***
Student Member ** (ADM/Ingegraf/AIP-PRIMECA) / € 380 / € 400 / € 500
Student * / € 380 / € 430 / € 530
Regular Member ** (ADM/Ingegraf/ AIP-PRIMECA) / € 580 / € 620 / € 720
Regular / € 580 / € 650 / € 750
Accompanying person / € 200

* Students/Ph.D students must provide proof of student status.

** It includes members of the Scientific Committee. Members of the Associations must provide proof of membership status.

*** Registration is available on the conference site.

The registration fee includes:

-  participation to the conference program

-  access to poster sessions

-  one copy of the papers abstracts

-  one CD of conference proceedings

-  coffee breaks

-  lunches, dinners and gala dinner ****

-  web connection

**** Accompanying person will benefit from the meals in the canteen in San Servolo and the gala dinner in Torcello

Leisure activities:

I’m interested in taking part in the following initiatives:

brief excursions in Venice, excursion: “Tour of Padua”, that will be held on 18th June 2011

Methods of payment

Accompanying person: / First name / Last name
First name / Last name
First name / Last name

Registration total amount: Participant: € ______

Accompanying person/s: € ______

Total: € ______

Please indicate the method of payment you are using (all payments are to be made in Euro, net of all bank charges and commission):

  Bank transfer to Banca Antonveneta, IBAN: IT62I0504012120000000163249
Account holder: Libreria Internazionale Cortina srl, Padova

Reason for payment: Event name and Participant's name.
A copy of the bank transfer order should be faxed or sent by mail together with the registration form.

I authorize Libreria Internazionale Cortina srl to charge my credit card for the amount of € ______

VISA MasterCard

Credit card number ______

Security code______Expiration date ______

Cardholder's name ______

Cardholder's signature ______

Data for invoice

The invoice must be addressed to:

Company name or Full name ______

VAT registration number ______Fiscal code (if any) ______

Address______City ______

State/Province ______Postal/Zip code ______Country ______

Please send the invoice to:

Address______City ______

State/Province ______Postal/Zip code ______Country ______

Changes, cancellations and refunds

Changes and cancellations must be sent in writing to LIBRERIA INT.LE CORTINA

Refunds (less € 20 handling fee) may be obtained for cancellations received up to March 15th. No refunds will be paid for any cancellation made after that date.

It is always possible to replace the registered participant, as long as this is communicated before the beginning of the event. In case of dispute, the court in charge will exclusively be that of Padua.

Personal data handling

In accordance with the Italian Law No. 675/96 we hereby declare that any personal information in our possession will be used only for the purposes of the meeting.

Date ______Signature ______

For Italian Citizens Only - solo per cittadini italiani
Nota per i dipendenti di Enti Pubblici. Le Pubbliche Amministrazioni che iscriveranno i propri dipendenti, per poter usufruire dell'esenzione IVA ai sensi dell'art. 10 del DPR 633/72 - come modificato dall'art.14, comma 10 della legge 24 dicembre 1993, n. 537 - dovranno inviare via fax (049 8754728), unitamente alla stampa dell'e-mail di riepilogo dell'iscrizione, una dichiarazione (contenente tutti i dati fiscali dell'Ente, nome del dipendente e titolo del congresso) in cui si specifichi che il partecipante per cui viene pagata la quota d'iscrizione è un loro dipendente autorizzato a frequentare l'evento. Si accettano anche autocertificazioni, con documento di identità allegato, contenenti le stesse informazioni. La fattura verrà intestata all'Ente di appartenenza.
Non verranno accettate richieste di modifica delle fatture già emesse o di rimborso dell'IVA versata.

For organizing secretariat use only.

Participant full name ______ID n° ……..

Registration form Social events reservation form Payment of € ______date ______

June 15th – 17th, 2011, Venice, Italy Registration form for IMProVe 2011