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Registration for June 8th, 2009 PRICE Individual Registration Form to the Colloquium 13

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Individual Registration Form to the Colloquium 13

PRICE

Opening of a European Workshop on Analysis of Primary Care Practices organised by the Maison des sciences de l’homme Ange-Guépin Registration for June 8th, 2009

Please return the registration form by April 15

th

, 2009 Only one form per person

Please note that seating is limited to 50

Identification

Identity ® Mr ® Mrs ® Miss

First Name

...

Last Name

...

Function

...

Affiliation

...

Adress

...

Zip code

...

City

...

Country

...

Phone

...

E-mail

...

Language chosen for the documents provided in the briefcases

The conference will be held in both French and English. A powerpoint presentation in the other language will be shown during each presentation. The documents will be available in French or in English depending on your choice (please tick accordingly below). You will also be able to find them online or to receive them per E-mail, provided you write your E-mail address on this form.

French ® English ® Transport

Please let us know if you wish to benefit from special transportation prices :

“Pass Cité” (day ticket for transportation in Nantes) ® Special fare with : SNCF (rail) ®

AIR France ®

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Registration Fees

Full Price ® € 29.50 (VAT included) Student Price ® € 19.50 (VAT included)

The fees cover the participation to the conference, coffee breaks, lunch (lunch box), a small conference briefcase and conference documentation.

Tick as appropriate

® I will attend the aperitif (free of charge)

Amount :

...

€ (VAT included) (VAT included 19,6%)

Payment

® By check in Euros made out to MSH Ange-Guépin

Any registration without payment will not be processed

Registration form to be sent with payment before April 15

th

, 2009 to : Dumontier Christel

MSH Ange-Guépin 5 allée Jacques Berque

BP 12105

44021 Nantes Cedex 1 christel.dumontier@univ-nantes.fr

02 40 48 39 47

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