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Registration Form

La statistique au service de la collectivité. Hommage à Louis-Paul Rivest pour ses 60 ans

August 29 - 29, 2014




*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)

Category * $ CAD
TOTAL $ CAD

Method of payment:

Cheque payable to Centre de recherches mathématiques (drawn on Canadian or US bank only)

International money order payable to Centre de recherches mathématiques (drawn on Canadian or US bank only)

VISA Credit card

MasterCard Credit Card

If you are paying by cheque or money order, or if you prefer to send your credit card information by mail, our postal address is:

Centre de recherches mathématiques
Université de Montréal
Case postale 6128, succursale Centre-ville
Montréal (Québec) H3C 3J7

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

Cardholder Name
Number (16 digits without space)
Expiry Date

Accommodation:

Would you like the CRM to book accommodation for you?		Yes	No
Hotel (list of hotels)
First choice
Second choice

Occupancy: Single Double

Date of arrival at hotel
Time of arrival at hotel
Date of departure from hotel

Important: In order to guarantee your hotel reservation,
please enter credit card information in the section "Method of payment",
even if you have chosen a different payment method.

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...

 


June 12, 2014, webmestre@CRM.UMontreal.CA