Workshop in Nonlinear PDEs Brussels, September 7-‐11, 2015 REGISTRATION FORM Secretariat Use Only Date Received: Mail address : PDE2015 ULB CP 213 Boulevard du Triomphe B-‐1050 Bruxelles Belgium Registration No.: Fax : +32 (0)2 650 58 67 Phone : +32 (0) 2 650 58 41 or +32 (0) 2 650 59 00 Email : [email protected] Web : http://pde2015.ulb.ac.be Please send this form by mail or fax to the workshop secretariat. If you do not provide credit card information, you can also send the form directly by email. Should you have any question, please contact us by email at [email protected]. Personal information (please type or write clearly in CAPITAL LETTERS) *All fields marked with a star are required for registration *Title ☐ Mr. ☐ Mrs. ☐ Ms. ☐ Prof. ☐ Dr. ☐ Phd student ☐ Others (Please specify _________) *First (Given) Name *Last (Family) Name Name for the badge Passport number Birthday: (yyy/mm/dd) / / *Affiliation Postal address Postal code City *Country Fax : (country code – area code – tel no.) Tel *Email address Payement Registration fee: Regular fee Later fee after before June 15 June 15 Professors and permanent ☐ 100 EUR ☐ 150 EUR researchers Phd students and Post-‐ docs ☐ 60 EUR ☐ 90 EUR TOTAL Quantity Subtotal EUR _______________ An attendance certificate and an official receipt for the registration fee will be delivered onsite. *Payment method ☐ Bank transfer : Europeans should use this method Account Owner Secretariat Use Only Université Libre de Bruxelles Transfer Received on: FORTIS Banque, Agence Pesage Av. du Pesage, 16 1050 Bruxelles – BELGIUM IBAN Code: BE79 2100 4294 0033 -‐ Code BIC: GEBABEBB MANDATORY communication: PDE2015 +++ Your name +++ 4R00F000025 If any bank charges apply, they must be paid by the ordering party. Within Europe, using SEPA facilities should be free of charges. Secretariat Use Only Card debited on: Credit card: Europeans should avoid this method ☐ Card type: ☐ VISA ☐ Mastercard ☐ Dinners ☐ AMEX Name of cardholder: _____________________________________________ Card n°.: Expiry date: ___ ___ (M) / __ __ (Y) CID-‐code: VISA/MASTERCARD/Dinners: last 3-‐digit number in reverse italics on the back of your card AMEX: 4-‐digit number on the front, above your card number Total amount: EUR _________________________________ Signature of cardholder: __________________________ Date: ____________________________