Registration Form

REGISTRATION FORM

PERSONAL DATA

SURNAME (family)

FIRST NAME

CITIZENSHIP

MALE / FEMALE

HOME PHONE NUMBER

PROFESSIONAL INFORMATION

POSITION

INSTITUTION

DEPARTMENT

STREET

CITY

COUNTRY

OFFICE PHONE NUMBER

E-MAIL

FAX	WWW ADDRESS

DO YOU BELONG TO THE "GEOMETRIC ANALYSIS" NETWORK ?

YES NO

*FOR STUDENTS ONLY*
HIGHEST UNIVERSITY DEGREE OBTAINED	YEAR
INSTITUTION	DATE OF BIRTH Month Day Year
ARE YOU A YOUNG RESEARCHER IN THE NETWORK ? YES NO

*ACCOMMODATION*
DATE OF ARRIVAL	DATE OF DEPARTURE
I WOULD PREFER A SINGLE ROOM IF AVAILABLE YES NO
I WOULD LIKE TO SHARE THE ROOM WITH
SPECIAL NEEDS (food, accommodation, arrival or departure days,...)