Fill this form  and send it by mail (not email) or fax  to

Jeanne-Marie COLLE
       Verimag
       Centre Equation, 2 av. de Vignate,
        38610 Gieres, France.
       Fax: (33-476) 6348-50
       Tel.: (33-476) 6348-57
       email:  jmcolle@imag.fr

Firt and last name:
Phone/Fax :                                                        Email :
Affiliation :
Street :
City :                                               Zip Code :
Country :
Additional remarks :

Participation fee :
Single room : 1000 francs                             [  ]
Double room : 850 francs  per person       [  ]
The fee include two hotel nigts, 2 breakfasts, 2 lunchs, 2 dinners and workshop participation.
Lunch on 16 th June costs 140 francs extra.
                                                             Yes  [  ]              No [   ]
Payment method : By credit card only VISA or EUROCARD

Credit card type :
Cardholders name :
Cardholders address :

Card number :
Expiration date :
Amount to be  charged :

Date and Signature :