MIME-Version: 1.0 Content-Location: file:///C:/9E74CAAD/RegistrationForm.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" Registration Form =

 

 

 

REGISTRATION FORM

 

 

Last = Name

First Name

 

SIP Members

ASIP Members

Non Members

Training

 

City:

State:

Zip Code

Address:

Phone:

Fax:

e-mail:

 

solo per partecipanti italiani -= for italian partecipants only

 

 

Nato a:

Prov<= span style=3D'font-size:10.0pt;font-family:Arial'>:

Il:

Cod. = Fis.

p. IVA

professione

Specializzato in:

Iscritto all'Ordine/Colleg= io dei:

di:

Tessera n°

I declar= e to have paid following reservation rate:

 

  

On or

Be= fore June= 15

Af= ter June= 15

Sponsoring/Partecipating Society Members

€ 250,00

€ 300,00

Non M= embers

€ 300,00

€ 350,00

Training people

€ 200,00

€ 240,00

by

bank transfer (attach copy of payment)

postal transfer (attach copy of payment)

 

 

 

I give my consent of my personal data (On article 13 of D 196/2003. The law L. lgs. n. 196/2003 deals with the protection of personal data) L. 675/96=

 

Date

 

 

Signature

 

 

 

 

 

 

 

 

  

 

  

 

 

 

 

 

Print and send by fax to: +39 0984 854540 =

Or by mail to CS CENTRO SE= RVIZI via delle Mimose Pal. Terrieri

       &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;  87040 Castrolibero (CS)

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