IGCP 610 REGISTRATION FORM
Please fill this form in capital letters and forward it by e-mail to:
irmot@avalon-institute.org (Attn.: Dr. I. Motnenko)
Tel: + 1-204-4894569, Fax: +1-204-4895782	

PARTICIPANT/STUDENT/ACCOMPANYING PERSON (please use one for each person) 

Title (Prof., Dr., Mr., Mrs., Miss)
Sex (M/F)                           
First name                                                                                                      
Last name
Department
Instıtute / University / Company
Address
City / Town                                                                                                     
Postal code
Country
Telephone                                                                                                      
Fax
E-mail
REGISTRATION FEE (please mark the appropriate box)	

Category	Registration before August 31, 2014	Registration after August 31, 2014	
	Euro	Euro	
Participant 	 350	 400	
Accompanying person	 300	 350	
Student*	 200	 250	
TOTAL			
If you are planning to pay your Registration Fee upon arrival please mark the appropriate box here.	 400	
	 350	
	 250	
* Student identification is required
METHOD OF PAYMENT –must be indicated 	
 Bank transfer:  
SWIFT:			CUCXCATTVAN
Bank:			Assiniboine Credit Union, Bank: 879, Branch: 62307
Account No: 		1001 0089 2950
Account Name: 		Avalon Institute of Applied Science 
Bank address: 		1855 Grant Ave. Winnipeg MB R3N 1Z2 Canada
IBAN:			62307 879 100100892950
In this case, a copy of the transaction should be sent by mail, fax, or e-mail to Dr. Irena Motnenko
 Credit Card           Visa     Master Card 
Name of card holder: ………………………………………………………………………………………………………
Card No:...........................................................CCV no:...................(three last digits on the back of your Credit Card)                                                          Expiry Date: .....................................................................
I hereby authorise the Organising Committee to charge my above Credit Card with the registration fees noted on this form.

Date:...................................................                                  Signature:..........................................................................