Please send this form by mail to - [email protected]
For more information, contact Thierry Guermonprez: +33 6 77 22 19 44
o Dr o Prof. o Mrs o Mr I agree to receive from the organizer the information of the platinum partners (3 max)
Name: Adress:
First name: Zip Code:
Organization/Company: City:
Service / laboratory: Country:
Email: Phone:
Organization/Company: Person in charge:
Service/Laboratory: First name:
Adress: Email :
Zip Code: Phone:
City: Intracommunity VAT number :
Country: Order form:
Participant's contact details
Billing information (if different)
AFSEP member Total amount with Taxes :
Academia
Industry Bank transfer
Student Order form
Accompanying person Credit Card
Gala dinner for acc. person
Short course / Workshop
PhD-Plus Package I choose the Workshop
PhD-Plus Package UP Saclay I choose Short course N°
Your status Your payment
We will contact you to finalize the Credit Card payment.
Date & signature
Stamp
Tick
REGISTRATION FORM
