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: Italy+0461 810629
michelet@science.unitn.it

REGISTRATION FORM

Complex Analysis and Geometry - XXI

Levico Terme (Trento), June 2-7, 2013

Family Name:

First Name:

Citizenship:

Full address:

e-mail:

Present professional position:

I need financial support: Yes/No

I will share a double bedroom with:

Arrival date (standard: Sunday, June 2 afternoon):

Departure date (standard: Friday, June 7 lunch time):

Date:

Signature