ISL2016
Napoli, Italy - 12-17 June, 2016
REGISTRATION FORM
This form, together with copy of payment and eventual student certificate, have to be sent to:
Associazione Geotecnica Italiana (AGI) - fax +39 06 44361035 - e-mail: [email protected]
MR./MRS./MS. _______ FAMILY NAME: ________________________________ FIRST NAME: ____________________________________________
COMPANY/AFFILIATION: _________________________________________________________________________________________________
ADDRESS : _______________________________________________________________________________________________________________
POSTAL CODE: _______________
CITY: _________________________________ COUNTRY: ______________________________________
PHONE: _______________________
E-MAIL: ______________________________________________________________________________
Permission to publish name and email address in the final ISL 2016 symposium delegate list:
 yes
no
INVOICE TO (indicate VAT number when available – also Codice Fiscale for Italian companies/citizens): ___________________________________
________________________________________________________________________________________________________________________
REGISTRATION FEES - All prices quoted in Euro (€)
Full registration and payment before April 1st 2016
 AGI, ISRM, ISSMGE, IAEG member
 Non member
 Student (please, include certificate)
 Two-days registration
€ 850,00
€ 950,00
€ 500,00
€ 600,00
Full registration and payment on or after April 1st 2016
 AGI, ISRM, ISSMGE, IAEG member
 Non member
 Student (please, include certificate)
 Two-days registration
€ 950,00
€ 1.050,00
€ 550,00
€ 650,00
 Gala dinner
€ 100,00
n.b. for two days registrations, please indicate the days you will be attending:
 June 13 and 14;  June 16 and 17
n.b. for two days registrations, please indicate the days you will be attending:
 June 13 and 14;  June 16 and 17
Symposium Full Registration includes:
• admission to all Symposium sessions
• welcome reception
• lunches and coffee breaks
• Symposium Proceedings
Quantity
Amount
TOTAL PRICE
PAYMENT
The amount has been paid by:
 Bank transfer to:
Associazione Geotecnica Italiana
IBAN: IT 81 G 02008 05003 000110084846
BIC/SWIFT: UNCRITM1B54
Bank name: Unicredit Banca – Agenzia Roma Testaccio
Please, remember to state company name and reason of payment. You are also reminded that bank charges are made and are deducted by the
bank before passing to AGI; it is therefore essential that all transfers of money include any surcharge. Deductions suffered by AGI should be
paid at registration.
 Credit card:
I authorise to charge my Credit Card
 VISA
 MASTERCARD
Card No. __________________________________________________________
 AMERICAN EXPRESS
Expiry date _________________________
Amount Euro _________________________ Name of cardholder: ________________________________________________
Date ______________________
Signature ___________________________________________________________
PLEASE NOTE THAT IF THE PAYMENT WILL BE MADE BY CREDIT CARD THE FORM HAS TO BE SIGNED
We hereby inform you that, in conformity with art.10 of Italian Law n.675/96, the information you provide filling in this form, will be collected in a data bank and may be
processed, also making use of third parties in compliance with the above mentioned law, for the purpose of commercial information and anonymous statistical
processing. Please, note that you are entitled to exercise the right specified in article 13 of the above mentioned law.
Date and signature
________________________________________________________________________________________________