European Worm Meeting 2006
Crete, 29 April – 3 May

REGISTRATION FORM

(To be sent as an e-mail message, attachment to: ewm2006@imbb.forth.gr, or faxed to +30-2810-391101)

PERSONAL DETAILS
First name:		Last name:		
						
Title:	Prof.		Dr.		Mrs.		Mr.		Gender:	Male		Female		
Affiliation:		
Street address:		
	Zip code:		City:		Country:		
e-mail address:		

REGISTRATION FEES
[please check: X]	
Early registration
(deposits until 24 March 2006)	Late registration
(after 24 March 2006)	
				
		390 Euro			440 Euro	

Preferable T-shirt size :	:	S		M		L		XL		XXL			

PAYMENT METHODS
Your registration is considered completed ONLY when registration fees are deposited

Bank Transfer [must be made without any charges for the recipient]
Bank	:	PIRAEUS BANK
Address	:	Science & Technology Park Branch, Heraklion 71110 Crete, Greece
BIC	:	PIRBGRAA
Account Number	:	GR23-0172-7550-0057-5502-4617-652
Account Holder	:	Georgia Houlaki [EWM2006 Secretary]
Don’t forget to mention your name when depositing the fees and send the remittance statement by fax to: +30 2810 391101 [c/o G. Houlaki]

Credit Card [You are advised NOT to send credit card details electronically. In this case, do not send the form as e-mail message attachment. Please submit the form by fax to +30 2810 391101 - c/o G. Houlaki]
Card type	:	VISA		Master Card		AmEx		Other			

Card number	:					-					-					-					

Valid	:	from			/			to			/			CVV*				
		M	M		Y	Y		M	M		Y	Y						
Holder’s name:		Signature:		

* CVV: The last 3 digits of the number at the back of the credit card