Registration Form for ICDT and/or WebDyn



Please edit this form electronically.


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First name:

Last name:

Title:

Affiliation:

Work address:

Postal/Zip code:

Country:

Phone:

Fax:

E-mail:

Participate in ICDT conference only (yes/no ) ? :

Participate in Web Dynamics workshop only (yes/no) ? :

Participate in both Web Dynamics workshop and ICDT conference (yes/no) ? :

Sub-total for registration fees (in pounds) :

Number of extra tickets for ICDT excursion+dinner on 5th Jan. :

Sub-total for extra tickets cost (in pounds) :

Special food requirements:

Accomodation in student halls required ? (If yes, indicate which nights):

Sub-total for student hall accomodation cost (in pounds):

Do you wish to receive an e-mail confirmation of this registration (yes/no)
?:

Payment type (credit card/personal cheque/bank cheque) ? :

Total payment due:

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Credit card details

For participants paying by credit card, please also fill in the following:

Card Type (VISA/Mastercard) :

Card Number:

Valid From (MM/YY):

Valid To (MM/YY):

Issue Number (for Switch cards only):

Date of birth:

Cardholder's name:

Address card is registered under (i.e. the address to which your credit
card statement is sent):

-

-

-

-

-

Cardholder's signature:




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Other payment methods

If not paying by credit card, please dispatch this form by regular mail,
accompanied by a personal cheque or bank cheque (in British pounds) for the
appropriate amount.