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REGISTRATION FORM
NAME
< compulsory
SURNAME
< compulsory
TITLE
INSTITUTE
DEPARTMENT
Specify if the address is :
Private Address
Institute Address
STREET
< compulsory
| Number
CITY
< compulsory
|
zip code
PROVINCE
COUNTRY
< compulsory
TELEPHONE
< compulsory
TELEPHONE 2
|
Fax
E-MAIL
< compulsory
NOTES
:
REGISTRATION FEE
Participant
€ 100,00
METHOD OF PAYMENT
>>
Bank cheque
"non-negotiable" in favour of
Avenue Media
>>
Wire Transfer
from Italy:
Banca Popolare dell'Emilia Romagna, Bologna - Agenzia n° 7 - current account n° 437531 in favor of Avenue Media S.r.l. - ABI 5387 - CAB 02406
from EU:
code IBAN: IT15V0538702406000000437531 - codice BIC: BPMOIT22
from abroad:
SWIFT BPMOIT22 - current account n° 437531
>>
Credit Card On-Line
(encrypted datab)
After clicking
on the
"send"
button (bottom of the form) you will be automatically redirected to the on-line payment page.
INVOICING
Made out to
Address
| n
City
|
Postal/Zip code
Province
Country
NOTE:
Privacy details
Privacy ActData marked by a (*) are not compulsory. However, failure to provide this data undermines the effectiveness and performance of the service. Data without (*) are used for administrative and fiscal purposes; you need to provide it in order to be enrolled. All the data will be gathered and processed (both manually and by computer) in compliance with the Italian legislative decree No.196/2003, also for the purpose of sending information and/or promotional material. Data will not be disseminated to external bodies, except for banks, mail delivery companies, service management companies appointed by Avenue Media, the Congress Scientific Secretariat and/or Organizing Committee. You are entitled to ask Avenue Media to update or delete your data or you can deny your permission to use it by writing to the company in charge of data processing: AVENUE MEDIA S.R.L., VIA RIVA RENO, 61 - 40122 BOLOGNA – ITALY (avenuemedia@avenuemedia.eu). You can find the entire law text containing the statement of your rights on our Web site: www.avenuemedia.eu – see “Privacy Act” link.
YES
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NO
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