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Registration Form

Conference on Topology, Geometry and Dynamics. In honour of François Lalonde

August 31 - September 4, 2015




*Mandatory fields

Title *

Occupation Status *

Gender *

Surname *
Given name *
Institution *
Institutional Address
Department *
Address *
City *
Province/State *
Postal/Zip Code *
Country *
Mailing Address (if different from above)
Department
Address
City
Province/State
Postal/Zip Code
Country
Telephones and WEB
To include a phone number on the American continent, write the code area followed by the phone number. For international phone numbers, write a + before the country calling code followed by the phone number. If there is an extension, write x and the extension number.
Office Telephone *
Home Telephone
Fax
Cell Phone
Email address *
WEB address http://

Registration Fees
(non-refundable)

A banquet will take place during the week. All those wishing to participate should indicate hereby the number of banquet tickets required. The cost per ticket is $70 CDN.

 

Category * $ CAD
Number of banquet tickets required:$ CAN
Please indicate in the field "Further information" any food restriction.
TOTAL $ CAD

Method of payment:

VISA Credit card

MasterCard Credit Card

Credit card information (must be valid until the beginning of the workshop):

Cardholder Name
Number (16 digits without space)
Expiry Date

 

Further Information

Please enter any further information or explanatory comments which you would like to include with your registration.

If you have completed this form...

 


January 26, 2015, webmestre@CRM.UMontreal.CA