Registration Form

Soil conservation management, perception and policy

(June 5-7, 2005, Mont Saint Aignan, France)

Early Registration form To be sent before May 15, 2005 with payment to

Agent comptable secondaire de l'INRA Versailles
INRA Versailles, Service déconcentré d'appui à la recherche
Route de Saint-Cyr, 78026 Versailles Cedex, France
Fax: +33 1 30 83 37 87                     E-mail: darthout@versailles.inra.fr

PLEASE, USE CAPITAL LETTERS TO FILL THIS FORM

Surname:                                        First Name:

Affiliation:

Mailing address:

Zip Code:                                       City:                                        Country:

Phone:                                        E-mail:

Registration Fee:

Before May 15 , 2005
After May 15 , 2005 ¨
c Ordinary participants 170 € c All participants: 200 €
c ESSC/AFES members: 150 €    
c Ph.D. Students: 100 €    

Payment

By Credit Card

c Visa              c Eurocard              c Card Mastercard

Expiration date:

Card number:

Cardholder's surname:                                        First Name:

Address:

I hereby authorize the Agent Comptable secondaire INRA to debit my credit card with the registration fee as quoted above for an amount of               €.

Date :                                   Signature :

By Bank Draft

Important: the payer supports all bank fees. Please give your name in your draft order when you will specify the reason of payment and send us a copy of this draft order, joined to your reservation request.

Name: INRA Versailles Agence Comptable secondaire
Address: Route de Saint-Cyr, 78026 Versailles Cedex, France
Bank Name: TP VERSAILLES
Agency Code: 10071
Desk Code: 78000
Account number 00001003980
RIB Key: 79

IBAN: FR76 1007 1780 0000 0010 0398 079
BIC: BDFEFRPPXXX