HCI-ET Applications Form

Surname:....................................................................................................

Firstname:..................................................................................................

Affiliation:...................................................................................................

Address:....................................................................................................

E-mail:.......................................................................................................

Phone:.......................................................................................................

Fax:...........................................................................................................



Registration

Total for registration ...........................................



Accommodation

Please reserve for me:

Date of arrival: ............................................................
Date of departure: .......................................................
Number of nights:.........................................................

Total for accommodation .......................



Payment

TOTAL: ............... USD

Please mark your choice:



Any special requests: (food preferences, etc.): ...................................... ............................................................................................................ ............................................................................................................