ICERS12 Registration Form
PARTICIPANT
Name
*
Surname
*
Title
*
Prof.
Dr.
Mr.
Mrs.
Ms.
Badge Name
*
Institute/University/Company
*
Postal Code
City
*
Country
*
COMMUNICATION
Phone
*
E-mail
*
CONFERENCE PARTICIPATION
Dietary Requirements(if any)
Accessibility
Other special requirements
Day 1 attendance
*
Day 2 attendance
*
Will you be attending the banquet dinner?
*
Yes
No
Paid
*
Yes
No
If paid please enter payment confirmation numbers
Number of registrations:
17