Registration Form

Personal data
Title:	Prof. Dr. Mr. Mrs. Ms.
Other title (please specify)
Mandatory field First name*
Middle name (optional)
Mandatory field Last name*
Telefon number (country code-city code-telefon number)
Mobile phone number (with a country code)
Mandatory field E-mail address*
An email message confirming receipt of payment will be sent to the address provided above. Please bring the confirmation message with you to the registration desk to facilitate the registration process. Places in the conference will not be held without payment of the registration fee.
Organization
Name of Organization
Formal position
Postal address
Postal code
Country
Phone number (with a country code)
Fax number (country code-city code-telefon number):
E-mail address
Internet address (www)
Special dietary requirements
	None Vegeterian No beef No pork No sea food
Other (please specify)
Program attending
	17.11.2011 -supper 18.11.2011 - conference sessions 18.11.2011 - CASE 20th Anniversary Dinner 19.11.2011 - conference sessions
Participation fee: 320 PLN (appr 80 Euro) for business and institutions 160 PLN (appr 40 Euro) for researchers and academics 0 PLN for Students and PhD students Please pay the conference fee by bank transfer to the account of the Please make sure as well that you cover all banking costs. In case of paying in other currency than Polish Zloty please reassure that we will receive the exact fee amount in Zloty on our Polish bank account. Please inform us in advance if you wish for an invoice to be issued. CASE - Center for Social and Economic Research Ul. Sienkiewicza 12, 00-010 Warszawa Account number: 54 1140 1010 0000 2230 6600 1036 IBAN : PL54 1140 1010 0000 2230 6600 1036 SWIFT: BREXPLPW Title: 2011 conference fee (and first and last name of the participant) Any cancellation or change must be received and confirmed by the Conference Secretariat in official written notice via letter, fax or e-mail before 1.10.2011 for 70% refund of total payment. No refund will be granted after this date or for no-show. The refund will be processed one month after the conference, less the applicable taxes and bank handling charges.
Mandatory field Spam security question* Please add 4 and 5.	Please add 4 and 5.

Registration Form

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