Polish Neuroscience Society 8th International Congress

Registration Form

Note: Fields marked in red must be completed!

If you are already registered in "Conference on-line service" please log in.

Please fill in information that let us identify you

Degree/Title	First Name	Surname	Sex

Choose a login name and password to register to the system:

Enter a valid email address for us to contact you:

Institution details:

Institution

Department

Address

Postcode City

Country

Telephone (incl. Country code)

2nd Telephone

Fax

Choose participation type:
PNS member 550,- PLN
Non-members 650,- PLN
Ph.D. Student 300,- PLN
Undergraduate Student, free of charge
Accompanying person, 250,- PLN
Invited speaker, free of charge
One day only, 150,- PLN

I would like to book and pay for the lunch during the congress:
lunch on September 25, 2007, price: 20,- PLN
lunch on September 26, 2007, price: 20,- PLN

Invoice details:
Would you like to receive an invoice:

Recipient:

Name/ Institution

Address

Postcode City

Country

VAT No.

Delivery address:

Name / Institution

Address

Postcode City

Country

I agree to receive information by electronic mail according to the Polish Act (Dz.U. z 2002, nr 144, poz. 1204). I hearby retain my right to access and correct my personal data.The organizers assure that your data shall not be made available to other companies or people without prior notification and your consent. The data is protected under the Data Protection Act (Dz. U. Nr 133/97, pos. 883).