Registration Form for Students, Postdoctorates and High School Teachers

REGISTRATION FORM FOR STUDENTS, POSTDOCTORATES AND HIGH SCHOOL TEACHERS

Pleasereturn this form within July 31thto:
Organising Secretariat
Fax +39 02 76406966

Thirteenth World Conference on The Future of Science

“Science and Society: science for a better life”

Fondazione Giorgio Cini, Venezia

September 21-22, 2017

Instructions:

Please note that the information below will be reproduced in the conference lists and will be used for all communications.Please type or write in BLOCK LETTERS.Seat availability is limited.

PERSONAL DETAILS

Title (Prof., Dr., Mr., Mrs., Ms., Miss)……………………………………………………………………………….…………...
Family Name ……………………………………………………………………………………………………………….…………….
First Name ………………………………………………………………………………………….………………………......
Age : □ under 30 □ 30-50 □ 50-70 □ over 70
Institute ……………………………………………………………………………….…………………………………......
Position …………………………………………………………………………………………………….………………......
Address ………………………………………………………………………………………………….…………………......
Zip Code and City ………………………………………………………………………………………………………......
State/Country ……………………………………………………………………………………….……………......
Telephone …………………………………….. Fax …………………………………….………………………......
E-mail……………………………………………………………………………………….……………………......

REDUCED REGISTRATION FEE:

/ Euro 50,00
Required document. Enclose copies of certificates.
For students: a copy of your valid student card. For PhD students and postdocs: a certificate of attendance from the Department's Director. For teachers: a document from your school certifying that you work there.
CONFERENCE PROGRAMME
Please tick the sessions you plan to attend:
□ Thursday, Sept. 21th
□ Friday, Sept. 22th
SOCIAL EVENTS
Please tick the events you plan to attend:
Thursday, Sept.21th / □ Opening Ceremony and Welcome Cocktail, Fondazione Cini

REGISTRATION FEE COVERS

Access to all scientific sessions;
One ticket to the Opening Ceremony and welcome reception at Fondazione Cini on Thursday, September 21th;
Coffee breaks,lunch, September 22th;
Daily transport from S.Marco to Conference venue and return;
BADGE AND CONFERENCE KIT
Your badge and Conference Kit can be collected from the Registration Desk at the Fondazione G.Cini beginning on the afternoon of September 21th.
Please note that badge is the only official evidence of registration and is required to attend all Conference activities.

ON REQUEST: RECEIPT DETAILS

Title (Prof., Dr., Mr., Mrs., Ms., Miss)………………………………………………………………………………......
Family Name ………………………………………………………………………………………………………......
First Name ………………………………………………………………………………………….………………......
Organisation/Institute/Company ……………………………………………………………………………….…......
Address ………………………………………………………………………………………………….…………......
Zip Code and City …………………………………………………………………………………………………......
State/Country ……………………………………………………………………………………….……………......
VAT Code (EU Countries only)…………………………………………………………………………......

Fondazione Umberto Veronesi, as no-profit organization, is not entitled to issue invoices. To certify your liberal outpayment Fondazione Umberto Veronesi, on request , issues a receipt that is tax deductible to the extent allowed by law.

BY BANK TRANSFER:

Accountno. 12810X39 Fondazione Umberto Veronesi

Banca Popolare di Sondrio sede di Milano

ABI 05696, CAB 01600, CIN M,
IBAN IT52 M056 9601 6000 0001 2810 x39

Object of payment: “Venice Conference 2017”

Please enclose copy of the bank transfer statement.

TOTAL AMOUNT ENCLOSED: EURO…………………………………………………………...………..

DATE………………………………...SIGNATURE…………………………………………………………….

Please note that your registration can only be confirmed after receipt of the full payment.

A written confirmation will be forwarded as soon as your registration has been duly processed.

[ x ] I have been informed that my personal data will be processed by the Umberto Veronesi Foundation as allowed by italian law 196/03 and am aware of my rights under that law. By completing and submitting this form, I give my consent for my personal data to be processed, for the purposes mentioned in the information note available on the website.

[ x ]I have read the Conference cancellation policy and accept the conditions.

All prices are in Euro.

SIGNATURE………………………………………………………