REGISTRATION FORM

REGISTRATION FORM

(please check the corresponding box)

€ I intend to participate at Congress sessions

€ I intend to send €1 €2 €more abstract(s) with the following title(s):

1. ______________________________________________________________

2. ______________________________________________________________

3. ______________________________________________________________

€ Oral presentation €Poster €Power-Point Presentation €Retroprojector

€ I am interested to become a member of Dacia Revival International

First name: ___________________________________________________________

Last name: _________________________________________________________

Date of birth: __/__/____ (month/day/year)

Position/Profession: _________________________/___________________________

Work company: _____________________________________________________

Telephone: _____________/_____________ Fax: ______________

E-mail: ______________________________________________

Address: ______________________________________________

Postal code: __________ Town: _____________________ Country: ___________

Other things you want to specify:

___________________________________________________________________

Complete this Form and send it to the organizing committee using one of the following:

Dacia Revival International

Str. Orzari nr. 15
Bucharest, 021551
Romania

Attn. Andrei Banica

Telephone: +40 726 113 151

+40 21 315 7282

Fax: +40 21 321 5354

By e-mail to: daciacongress2006@gmail.comYou cand download the electronic version of this Form from the Congress page: www.dacia.org/2006

If you have any questions you can contact us by phone or by e-mail at daciacongress2006@gmail.com sau mail@dacia.org