IC-EATCS 1997 Advanced School

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                             APPLICATION FORM
                             

Family name: _____________________  Name: ___________________________

Date of Birth: ___________________  Cytizenship: ____________________

Position: __________________  Affiliation: __________________________

Address: ____________________________________________________________

Phone: ________________  Fax: ______________  Email: ________________

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Please select your preferred form of payment for the fee
by replacing the "o" with an "*"

o Check of Lire: ___________ sent to CISM.

o Payment of Lire: ___________ made on CISM Bank Account N. 3000, 
  ROLO Banca 1473, Agenzia 2, UDINE (ABI 3556, CAB 12303). 
  Bank transfer must be free of charge for the organizers.

o Charge of Lire  on the Credit card: _______________________
  (Cartasi, Eurocard, Mastercard or Visa)

  Number: _________________________  Expiration date: _______

  Name on card: _____________________________________________

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Please indicate to whom the invoice should be addressed here below. This
name should also appear on all bank documents

Name: ______________________________________________

Address: ___________________________________________

VAT number or Fiscal Number: _______________________
(Only for EC or Italian residents or foreigners with permanent business 
activity in Italy):