INDIVIDUAL REGISTRATION FORM
PEKEA IVth World Conference and General Assemby
Rennes - 4 to 6 November 2005

Late registration after 15 October

Registration form to download as a word file (.doc)
to print, to fill and send by e-mail, fax or post
with your payment or indication

Registered participants will receive the Conference Papers, a badge to enter the conference rooms

and a pass to have lunches at a restaurant during the conference

This form must be filled completely by any participant; keep a copy for your record and send the original to

PEKEA Office by post, fax or by attached file with an e-mail.

Last name	First name
Mr or Ms	Organisation
Address	Zip code
Country	Phone n°
e-mail	Fax n°

Registration fee: Please tick one category in the table then tick one mode of payment below

Full rate : ordinary participant	Reduced rate : Pekea individual member or member of a partner organisation.	Special rate (unemployed / student/ Author)
□  Payment in Euros : 60 € □	□ Payment in Euros :20 € □	□ Payment in Euros :10 € □

Payment in Euros :   

□ Cheque on a European Bank to PEKEA Office, Maison du Ronceray, 110 rue de la Poterie, 35 200 Rennes, France,

Tel/Fax +33 (0)2 99 86 17 35, to send with a copy of this form.

□ Transfer the amount in Euros, net of any commission for PEKEA to BPO bank account:

IBAN n° FR76 1670 7000 2091 0190 3218 290

□ I have made a payment by card on PEKEA Web, find herewith a copy of the receipt.

□ Please invoice to ( attached an order form)

Registrations become valid when payment is received or duly committed.

Date :

Signature :