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REGISTRATION
Gauge Theories, Monopoles, Moduli Spaces and Integrable Systems. A Conference honouring Jacques Hurtubise on his 60th birthday
August 21 - 25, 2017
* MANDATORY FIELDS
IDENTIFICATION*
TITLE*
Ms
Mr
Dr
Professor
Professor Dr
NAME*
Given Name
Family Name
OCCUPATION*
FACULTY/RESEARCHER - WITH GRANT
FACULTY/RESEARCHER - WITHOUT GRANT
POSTDOCTORAL FELLOW
GRADUATE STUDENT (2ND AND 3RD CYCLE)
UNDERGRADUATE STUDENT
ELEMENTARY OR SECONDARY SCHOOL PROFESSOR
INDUSTRIAL RESEARCHER (Industry, Finance, etc.)
UNEMPLOYED
SELF-EMPLOYED
Other
SEX* (for statistical purposes)
Female
Male
AFFILIATION*
Affiliation
Department
Address of Affiliation
City
Postal Code / Zip Code
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CORRESPONDENCE ADDRESS
Please fill out the following if different from the affiliation.
Correspondence address
Address
City
Postal Code / Zip Code
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Please choose a state, province or area:
TELEPHONE (with dialing code), EMAIL ADDRESS AND WEB SITE
Email address*
Secondary email address
Office phone*
Home phone
Fax
Cellular Phone
Web Address
Twitter
REGISTRATION FEES*
Registration fees are non-refundable.
Registration Fees $CAN
Please choose
Student
Postdoc Fellow
Faculty/Researcher - without grant or retired
Faculty/Researcher - with grant
Researcher Industry/Government Agency
Invited Participant
BANQUET
The cost of the banquet is 70 CAN$ per person.
Number of banquet tickets required
$CAN
Total banquet
Total banquet
Special menu. If yes, which one?
TOTAL FEES
Total fees $CAN
PAYMENT *
By credit card only.
Credit card information must be valid until the beginning of the workshop.
The following amount will be debited from your credit card.
Payment Card
Name of the credit card holder
Credit card number
Expiry date on credit card MM/YYYY
MISCELLANEOUS INFORMATION
Please write any other information or comment.
