REGISTRATION FORM:
   5th INTERNATIONAL WORKSHOP ON DCD
   
    Date >: 15/09/2018
    Location : University of Pavia
   On-line Registration will be available until 13th September 2018
 
   Family Name
   
 
   Name *
   
 
   Place of Birth *
   
 
   Date of Birth *
   
 
   ID *
   
 
   VAT number
   
 
   Profession/Specialization *
   
 
   Institute
   
 
   Professionale address
   
 
   Persona address *
   
 
   City *
   
 
   Town *
   
 
   Postal Code *
   
 
   Nation
   
 
   Phone *
   
 
   Mobile *
   
 
   Fax
   
 
   Intolerances/food allergies
   
 
   E-mail *
   
 
    Privacy
   
    I have read and I accept the above conditions
 
Select Option
Before 00/00/0000
Before 00/00/0000
After 00/00/0000
 
 
Payment Mode

Bank Transfer:
Owner : MI&T SRL
IT71I0638502403100000004376
Swift Code/Bic Code IBSPIT2BXXX
Description:

Credit Card (CartaSi, Visa, Visa Electron, Mastercard, American Express)
 
Amout to pay: