Family name :

First name :

Title :

Address :

Tel/fax :

E- mail :

Specialization :

I wish to participate in the EUROGIN Leader Meeting,
October 12 -14, 2001, Nice.

I will NOT attend the EUROGIN Leader Meeting, but would like to receive the work materials
I wish to book the special dinner and show at the Nice Casino on Friday 12 October, 2001. Please add 75 Euros to the registration fee (total 625 Euros)

The registration fee for the Expert Meeting is 550 Euros,
including lunch on Saturday 13 October 2001.
I choose the following method of payment: (Euros 550 or 625 Euros with Friday night dinner+show)

Credit Card (Visa or Mastercard), please indicate :

 

 

Name of card holder :

Card type :

Card number :

Expiry date :

Bank transfer (see account details below)

Chèque (French participants only, please send chèque by mail together with this form)


In case of payment by bank transfer please use the following bank details and enclose a copy of the bank transfer note with your registration. Transfer costs are at the sender's expense.

Account details EUROGIN,
International account number (IBAN): FR76 30003 03180 00050518262 24
SWIFT address: SOGEFRPP
Bank: SOCIETE GENERALE, Paris Villiers (30003 / 03180)

Please return this form completed to:
EUROGIN
174, rue de Courcelles
75017 PARIS, France
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