Inscription form

Conference Resurrection

Titel Mrs Miss Mr
Surname
First name
Function Professor Student Other
Address
Postcode and Town
Country
E-mail	[xxx@yyy... .zzz]
Phone
I will be at : the given reception of the Wednesday April 7th evening the closing dinner of the Friday April 9th evening (after an extra payment of 60 euros)

| 7/08/2009 |