‘DISLOCATIONS 2004’ REGISTRATION FORM
‘La Colle-sur-Loup’, French Riviera, FRANCE September 13 – 17, 2004

Please print out this form  (use  CAPITAL LETTERS), return the form by mail or by fax to :

Dislocations 2004 Secretariat, c/o Eric MARTIN
DELEGATION ILE-DE-FRANCE Ouest & Nord du CNRS
1 Place Aristide Briand – 92190 Meudon, France
Fax : +33  1 45 07 58 99

NAME : Mr / Ms /Mrs	
……………………………………………..
(Last or family Name)	
……………………………………………..
(First or Given Name)	
ADDRESS : Office, Home
……………………………………………………………………………………………………………….………………………………….………………………………………………………………………………………………..…….	
City :………………………………	Postal code /ZIP : …………………….	Country :…………………………	
Phone :    ……………………………………..                                Fax :……………………………………..	
E-mail : …………………………………….……………………………………..……………………………………..	

REGISTRATION  (*) :
	Advance Registration @ 400 € (Until June 30,2004)	…………………..…….€	
	Late/On-site Registration @ 450 €	…………………..…….€	
	Student (**) Registration @ 300 €	…………………..…….€	
	Late/On-site Student (**) Registration @ 350 €	…………………..…….€	
			
	Accommodation at VVF ‘La Bergerie’ (within Sept 12th and 17th) :		
	Full board in single room, from Sept. 12 th to Sept. 17 th @ 470 €	…………………..…….€	
	Full board in single from Sept. .… th to Sept. ….th @ (… x 110 €) 	…………………..…….€	
	Full board in shared double room, from Sept. 12 th to Sept. 17 th @ 375 €	…………………..…….€	
	Full board in shared double room, from Sept. .… th to Sept. ….th @ (… x 90 €)	…………………..…….€	
	Suggested room mate for double rooms (optional):		
			
	TOTAL	…………………..…….€	

PAYMENT OF REGISTRATION (before July 1st, 2004) may be made only in Euros as follows (select one) :
	Bank transfer in Euros to Banque de France : BDF Nanterre La Défense
Account owner : Trésorerie Générale des Hauts de Seine, pour le compte du CNRS
IBAN(International bank account number) FR76 4007 1920 0000 0030 0031  090
BIC (Bank Identifier Code) BDFEFRPPXXX
Please DO mention the object : ‘Dislocations 2004’. For international tranfers please make sure that the transfer is free of charge for to(?) the beneficiary	
	French attendees only : « Bon de commande » to send to ‘Dislocations 2004’ secretariat (address above)	
	Personal checks in Euros, payable to: Agent Comptable CNRS
(to be mailed with registration form)	
	Banker’s draft in Euro, payable to : Agent Comptable CNRS
(to be mailed with registration form)	
	Credit card: For payment by VISA, MASTER or EUROCARD, fill out also the following form and send both forms by mail/fax to the‘Dislocations 2004’ secretariat (address above)	
	ON-SITE payment will be accepted only in Euros with cash and personal checks	
*Registration fees include breackfast, lunch, dinner, drinks during meals, coffee breaks, service conference material, banquet participation, taxes and one copy of the conference proceedings.
**Students must also send an accompanying letter from  their supervisor certifying their status and a copy of their student card.

Reg. No.	Date	Payment	

		
	For official use only		

CREDIT CARD PAYMENT FORM

‘DISLOCATIONS 2004’
‘La Colle-sur-Loup’, French Riviera, FRANCE September 13 – 17, 2004

Name of Participant :……………………………………………………………………………………………

Please charge to the following credit card the charges for inscription and additional services.

	Amount :	………………………………………EUROS

	Type of Credit Card : 	 VISA /   MASTER /   EUROCARD

	Name of Card Holder :	…………………………………………….

	Credit Card Number :	…………………………………………….

	Expiration Date :	…………………………………………….

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

Please send the REGISTRATION FORM and this CREDIT CARD PAYMEN FORMT

by mail at: 
Dislocations 2004 Secretariat, c/o Eric MARTIN
DELEGATION ILE-DE-FRANCE Ouest & Nord du CNRS
1 Place Aristide Briand – 92190 Meudon, France

Or to the following FAX Number : + 33 – 1.46 73 41 55