Name and Surname

Address

Phone ________________ Fax ________________ e-mail ________________

Special status of participant (attach a copy of document to prove the status): O under 25 years O unemployed O pensioner

I intend to participate as: O presenting author O coauthor O without presentation O accompanying person

I intend to book a room in: O Adriatic Hotel O another place

Title of presentation:

Author(s) (underline presenting author)

Date _____________________ Signature ___________________________________________