The check or money order should be made payable to "Agent

REGISTRATION FORM
INTERNATIONAL CONFERENCE ON STATISTICS IN HEALTH SCIENCES
June 2004, 23-25, NANTES; FRANCE
Last Name:
First Name:
Organization/Institution:
Mailing Address:
Country:
Zip/Postal Code:
City:
Fax:
Email:
Telephone:
I would like to participate to the International Conference on Statistics in Health Sciences (the
registration fee includes the abstract book, all morning and afternoon coffee breaks, three lunches, the
welcome cocktail, and the gala dinner):
Before March 2004, 20:
❑ Regular Fee: ………………………………………………………………………… 300 €uros
❑ Student Fee*: ……………………………………………………………………… 200 €uros
After March 2004, 20:
❑ Regular Fee: ………………………………………………………………………… 330 €uros
❑ Student Fee*: ……………………………………………………………………… 230 €uros
In order for us to organize the lunches, could you fill the information below
Wednesday lunch, 23, june 2004
❑ yes ❑ no
Thursday lunch, 24, june 2004
Friday lunch, 25, june 2004
❑ yes ❑ no
❑ yes ❑ no
In order for us to organize the gala dinner, could you fill the information below
❑ Gala Dinner (registered participant): ……………………………………………… ❑ yes
❑ no
❑ Gala Dinner (accompanying person): ………………………………………………….. 50 €uros
Form of payment: ❑ Check
❑ Money order/bon de commande
❑ Bank transfer (see next page)
The check or money order should be made payable to "Agent Comptable de l'Université de Nantes"
*Please include documentation (student ID) of full-time student status at the time of registration
Send complete from with payment to: Monsieur le Professeur Jean-Louis AUGET
Faculté de Pharmacie
Laboratoire de Biomathématique et Biostatistique
1 rue Gaston Veil - 44035 Nantes cedex 01 – FRANCE
☺ Please confirm along with this registration form your registration by mail by sending your name and full
address to [email protected]
Check :
The check should be made payable to “ M. L’AGENT COMPTABLE DE L’UNIVERSITE DE NANTES”
Bank Transfer:
Bank name: TRESOR PUBLIC NANTES TRES GENERALE
Account name: M. L’AGENT COMPTABLE DE L’UNIVERSITE DE NANTES
1 QUAI DE TOURVILLE
BP 13522
44035 NANTES CEDEX 01
For international transfer: IBAN (International Bank Account Number):
|FR76| |1007| |1440| |0000| |0030| |0026| |478|
For national transfer:
Account number: 00003000264 78
NBC (National Bank Code) : 10071 44000
Purpose:
P1
MATPHYSANT
account
STAT and your name
(please quote these indications imperatively on your transfer form.)