Please send the form, preferably by e-mail, to

Augusto Micheletti, Secretary of CIRM
Fondazione Bruno Kessler

Via Sommarive, 14 - Povo
I-38123 Trento, Italy
fax: +39-0461-810629
augusto.micheletti@unitn.it

REGISTRATION FORM

School “The Hodge Conjecture: State of the Art”

Levico Terme (Trento), June 6^th – 10^th, 2016

Family Name:

First Name:

Age:

Sex:

Citizenship:

Full address:

e-mail:

Present professional position:

I need financial support:

I would like to share the room with:

Arrival date (standard: Monday, June 6^th morning):

Departure date (standard: Friday, June 10^th after lunch):

Date:

Signature