First name:   Family name:   Title:

Institution:

Department:

Street:

City:    ZIP code:    Country:

Phone (incl. country code):    Fax (incl. country code):

e-mail:

No. of accompanying persons: 

Oral communication:   yes    no

Tentative title and author(s):

Poster(s):    yes     no      (if yes, please give the number of posters: )

Tentative title(s) and authors:

Additional social program (paid)

I would like to participate in (no obligation at that moment):

Conference dinner:

Pre-conference tour to Kraków and Wieliczka:

Post-conference tour to Pszczyna:

     (total number of persons: )*

     (total number of persons: )*

     (total number of persons: )*

       * participant + accompanying persons