Please type or print details in block letters and return with payment to :

Armel Le Bail
Université du Maine, Laboratoire des Fluorures
Avenue O. Messiaen
72085 Le Mans Cedex 9
France

Tel :- +33 2 43 83 33 47 Fax:- +33 2 43 83 35 06

PERSONAL DETAILS

Family Name ………………………………..............……… Title ( Prof./Dr/Mr/Mrs/Ms/Other )…………………….……………

First Name ………………………………………

Address for Correspondence

Institution ……………………………………………………… Department ……………………………………………………………

Address……………………………………………………………………..……………………………………………………….………..

…………………………..……………………………………………………………………………………………………….…….………

City ……………………………..…… Post / Zip Code ……..…...….… Country…….…..……………………………………

Telephone ……………………………………………………. Fax …………………………………………………………………..

E-mail ..……………………………………………………………….……………………………………………………………………

REGISTRATION FEES - Students in a developing countries may ask for a discount - (in Euros) :
 

Students - Please have your Supervisor, or Department Head, sign here as proof of Student Status.

Name ………………..……......................…...........……….. Signature ……….….......................………………………………

Institution ………………………………………..........................…………………………..........................……………………

Payment can only be made by cheque or Banker’s draft in Euros payable to ‘Agence Comptable de L'Université du Maine', Trésorerie Générale,
IBAN (International Bank Account Number) :   FR76 1007 1720 0000 0010 0017 920
BIC (Bank Identifier Code) :   BDFEFRPPXXX

Bank address : TPLEMANS TRESOR GALE
                          23 Place des Comtes du Maine
                          72002 Le Mans cedex 01
                          France
 

Cancellation of the SDPD Course/Alteration of the SDPD Course
It is a condition of this booking that the SDPD Course organizers have the right for any reason beyond their control to alter or cancel, without prior notice, the Course or any of the arrangements, timetables, plans or other items relating directly or indirectly to the Course and that the SDPD Course organizers shall not be liable for any loss, damage, expenditure or any inconvenience caused as a result of such alteration or cancellation and in the event of cancellation of the Course the pre-paid registration fees will be returned in full.
 

Signature .............................................. Date ..........................
 
 
 
 

Complementary indications for the Université du Maine archives :
 
 

Date of birth :

Birthplace :

Nationality :

Last diploma (date, name, place, University) :
 
 

Current occupation :

Personal address :
 
 

If possible, send an identity photograph as a .jpg attached file.