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
michelet@science.unitn.it

REGISTRATION FORM

International Conference on “Recent Advances in PDEs and Applications”

(on occasion of Professor Hugo Beirão da Veiga’s 70^th birthday)

Levico Terme (Trento), February 17-21, 2014

Family Name:

First Name:

Citizenship:

Full address:

e-mail:

Present professional position:

Arrival date (standard: Sunday, February 16^th afternoon/evening):

Departure date (standard: Friday, February 21^st after lunch):

I would like to book a bedroom at Bellavista R. Hotel: - single

- double, to be shared with ……………………………..

Date:

Signature