Registration form (pdf file) - FatigueDesign 2015

18 & 19
er
Novemb
2015
ance
li
Sen s, Fr
Registration form
Online: www.fatiguedesign.org
or
Please return to:
[email protected] – Fax : +33 (0)3 44 67 36 94
Cetim – 52 avenue Félix-Louat – BP 80067 – 60304 Senlis Cedex – France
FOR MORE INFORMATION, PLEASE CONTACT:
Question Answer Service – Tel. : +33 (0)3 44 67 36 82 – www.fatiguedesign.org
n Mr
n Mrs
n Ms
Surname*...........................................................................................................................................................................................................................
First name*.......................................................................................................................................................................................................................
Quality*................................................................................................................................................................................................................................
E-mail*.................................................................................................................................................................................................................................
Company*.........................................................................................................................................................................................................................
Address*............................................................................................................................................................................................................................
Zip Code*.................................... City*.......................................................................................... Country*............................................................
Phone of the company*................................................ Fax.......................................................Mobile.............................................................
N° Siret............................................................................... Fiscal VAT Number.....................................................................................................
Business sector.............................................................................................. Size.....................................................................................................
• Shuttle Services: During all the event, dedicated shuttle services will be put in place between
the hotels and the conference site
Arrival Shuttle - Wednesday 18th
Roissy Charles de Gaulle -> Senlis*
n 7.00 am
n 7.45 am
Departure Shuttle - Thursday 19th
Senlis -> Roissy Charles de Gaulle*
n 6.15 pm
Hotel transfer (Senlis: Campanile, Ibis, Etap Hotel / Survilliers: Mercure, Campanile, Novotel)*
n Yes
n No
All usefull informations about these hotels are on www.fatiguedesign.org
* has to be completed
• These prices include contribution to conference expenses, supply of a conference proceedings, lunchs,
coffee breaks.
Registration fees
Before 25 september
After 25 september
Speaker
400 e **
470 e **
Participant
570 e **
670 e **
Membre AFM, SF2M, ECCS
Cetim’s subscribers
510 e **
590 e **
Students
300 e **
340 e **
Gala Evening
50 e **
50 e **
I will attend the Gala Evening :
Registration fee
e
Gala Evening participation
fees
Number:
Fees:
€
Total:
€
The speakers are kindly asked to register before June 19th, 2015.
(**) The rate includes TVA / VAT: 19,6%
• Payment must be made to the order of the Cetim*:
n by Bank check
n by Bank wire transfer
n by Credit card on-line payment on www.fatiguedesign.org
Code banque
Code guichet
N° de compte
Clé RIB
Domiciliation
30004
00074
00025684844
48
BNP PARIBAS
NORMANDIE PICARDIE
IBAN FR76 3000 4000 7400 0256 8484 448
BIC: BNPAFRPPCRO
Please mention the invoice and customer number on your transfer order
• You will receive an invoice with a confirmation of your registration.
• Cancellation requests must be sent before Friday 23 october 2015. Past this deadline, registration fees
shall not be reimbursed. However participants may be represented by a deputy on request.
• The organizers reserve the right to postpone the event, or to change the venue or the programme
should circumstances beyond their control arise.
* has to be completed
1503-025
Official stamp
Name of undersigned
Signature
Date