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5th International Veterinary Immunology Symposium TRAIN & HOTEL RESERVATION FORM Print out this form on A4 or letter size paper. Fill in the information in capital letters or type print and send the completed forms to the 5th IVIS Secretariat, Dr. A.S. Grewal (Mail: Department of Immunology, Punjab Agricultural University, Ludhiana 141 001, INDIA) (Fax: ++91-161-400945) (E-mail: [email protected]). Name: ____________________ ____________ ______________ Last name (Surname) First name Middle names Male ____ Female____ Designation:______________________ ................................................................................................................................................................. Correspondence/Mailing Address: Department ______________________ Institute _______________________________ City_________________________ State _________________________ Country_____________________ Postal Code____________________ Fax nr ++___-___-____________________ Tel nr ++___-___-_____________________ ( country code - area/city code - subscriber number) E-Mail Address: _______________________________ ................................................................................................................................................................. Student participants: A signature from the head of your institute is required to confirm your student status. ____________________________ ____________________ _________ Name of the Head/Chair (Signature) Date of the Department/Institute ................................................................................................................................................................. Accompanying Members: Names, gender and age (if twelve years or less) (1)_________________________(Male/Female) (2)_________________________(Male/Female) (3)_________________________(Male/Female) (4)_________________________(Male/Female) ................................................................................................................................................................. Full registration fee, 350 US$ before 1 May __________ 375 US$ before 1 August __________ 400 US$ after 1 August __________ Student registration fee, **** US$ __________ Meal plan ( US$) __________ Social Program: farewell dinner ( US$) __________ ...................................................................................................... TOTAL ( in US$) __________ Included is a bank demand draft of ........US$. Signature of participant Date |