Registration form (pdf file) - FatigueDesign 2015
18 & 19 er Novemb 2015 ance li Sen s, Fr Registration form Online: www.fatiguedesign.org or Please return to: [email protected] – Fax : +33 (0)3 44 67 36 94 Cetim – 52 avenue Félix-Louat – BP 80067 – 60304 Senlis Cedex – France FOR MORE INFORMATION, PLEASE CONTACT: Question Answer Service – Tel. : +33 (0)3 44 67 36 82 – www.fatiguedesign.org n Mr n Mrs n Ms Surname*........................................................................................................................................................................................................................... First name*....................................................................................................................................................................................................................... Quality*................................................................................................................................................................................................................................ E-mail*................................................................................................................................................................................................................................. Company*......................................................................................................................................................................................................................... Address*............................................................................................................................................................................................................................ Zip Code*.................................... City*.......................................................................................... Country*............................................................ Phone of the company*................................................ Fax.......................................................Mobile............................................................. N° Siret............................................................................... Fiscal VAT Number..................................................................................................... Business sector.............................................................................................. Size..................................................................................................... • Shuttle Services: During all the event, dedicated shuttle services will be put in place between the hotels and the conference site Arrival Shuttle - Wednesday 18th Roissy Charles de Gaulle -> Senlis* n 7.00 am n 7.45 am Departure Shuttle - Thursday 19th Senlis -> Roissy Charles de Gaulle* n 6.15 pm Hotel transfer (Senlis: Campanile, Ibis, Etap Hotel / Survilliers: Mercure, Campanile, Novotel)* n Yes n No All usefull informations about these hotels are on www.fatiguedesign.org * has to be completed • These prices include contribution to conference expenses, supply of a conference proceedings, lunchs, coffee breaks. Registration fees Before 25 september After 25 september Speaker 400 e ** 470 e ** Participant 570 e ** 670 e ** Membre AFM, SF2M, ECCS Cetim’s subscribers 510 e ** 590 e ** Students 300 e ** 340 e ** Gala Evening 50 e ** 50 e ** I will attend the Gala Evening : Registration fee e Gala Evening participation fees Number: Fees: € Total: € The speakers are kindly asked to register before June 19th, 2015. (**) The rate includes TVA / VAT: 19,6% • Payment must be made to the order of the Cetim*: n by Bank check n by Bank wire transfer n by Credit card on-line payment on www.fatiguedesign.org Code banque Code guichet N° de compte Clé RIB Domiciliation 30004 00074 00025684844 48 BNP PARIBAS NORMANDIE PICARDIE IBAN FR76 3000 4000 7400 0256 8484 448 BIC: BNPAFRPPCRO Please mention the invoice and customer number on your transfer order • You will receive an invoice with a confirmation of your registration. • Cancellation requests must be sent before Friday 23 october 2015. Past this deadline, registration fees shall not be reimbursed. However participants may be represented by a deputy on request. • The organizers reserve the right to postpone the event, or to change the venue or the programme should circumstances beyond their control arise. * has to be completed 1503-025 Official stamp Name of undersigned Signature Date
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