FAC - Speaker registration

Speaker registration

Please fill in the form below before February 28th, 2010 :

This form is a pre-registration and must be completed before payment. You can be pre-registered and pay later (the applicable rates are according the pre-registration date).

I am already pre-registered and I would like to pay : click here

SPEAKER PRE-REGISTRATION FORM

YOUR INFORMATION

Title	:
Last Name *	:
First Name *	:
Profession *	:
Company Name *	:
Address *	:
Country *	:
Your email *	:
Phone *	:
Mobile	:
Fax	:
Requirements (dietary, special access...)	:
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ABOUT YOUR PRESENTATION
Presentation title *	:
Author *	:
Co-author(s)	:
Speaker name (if different from the author)	:
Abstract (1200 words maximum)	:
Technical topics (select one or several appropriate topics) *	:

Speaker biography (1000 words maximum)	:	submission no later than February 28th, 2010
______________________________________________________________________________
YOUR REGISTRATION TO FAC2010 *	:	Tuesday 4th May 2010 (200 € ) Wednesday 5th May 2010 (200 € ) Thursday 6th May 2010 (200 € ) Friday 7th May 2010 (150 € ) Full Access - May 4-7th 2010 (450 € *)
* Early bird rate (before April 3rd 2010)
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PAYMENT INFORMATION
Payment mode	:
Invoice address (if different from your office address)	:
Intra-community VAT number (EU countries)	:
SIRET number (only France)	:
______________________________________________________________________________
I hereby acknowledge *	:
ownership of and give permission to publish my paper, PowerPoint presentation and photos
in .pdf, .jpeg or .gif format in the Proceedings of the Flow Accelerated Corrosion International
Conference FAC2010.
______________________________________________________________________________
* : Obligatory field