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
micheletti@fbk.eu

REGISTRATION FORM

Complex Analysis and Geometry - XXIII

Levico Terme (Trento), June 12-15, 2017

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 11 afternoon):

Departure date (standard: Thursday, June 15 lunch time):

Date:

Signature