Print out this registration form and send it to:

IMC 2005 - Jan Verbert
Public Observatory Urania
Jozef Mattheessensstraat 60
B-2540 Hove
Belgium

Name
First(*):
Middle:
Last(*):
Personal information
Phone:
E-mail:
Birthdate(*):	(YYYY-MM-DD)
Address
Street(*)
City(*)
Zip(*)
Country(*)
Additional information
I intend to travel by together with
I need travel information from                             to Oostmalle.
I wish to stay in Belgium before and/or after the IMC and would like additional information.
Vegetarian.
T-shirt: Size (S-M-L-XL):               Gender:
For participants wishing to contribute to the program
Lecture:
Requirements:	Duration:               min.
Workshop:
Poster:	Space:               m2

Comments









Either the entire fee of 120 EUR or a pre-payment of 60 EUR should be sent to the IMO Treasurer, Ina Rendtel. Follow the payment instructions. Participants making a pre-payment only have to pay the remaining 60 EUR in cash upon arrival in Oostmalle.