Registration Form

(1)

Italy-Japan Symposium on Nuclear Physics November 19-23 2012

Registration Form

Please print in block letters.

Surname: _______________________________ Given (First) Name: ________________________________

Institution / Organization: ___________________________________________________________________

Mailing Address:

________________________________________________________________________________________

Phone (with country and city code): ____________________________________

Fax (with country and city code): ____________________________________

E-mail: __________________________________________________________________________________

Arrival day ___________________________________________________________________

Departure day ___________________________________________________________________

Please remit this form by e-mail to:

Ileana Giussani

E-mail: [email protected] Phone: +39 02 50317248

Fax: +39 02 50317487