Registration form

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Centre National de la Recherche Scientifique

Institut d'Études Scientifiques de Cargèse

THERAPEUTIC ULTRASOUND

   September 28th - October 2nd, 2009

Cargèse, France

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REGISTRATION FORM

TO BE SENT (preferably by email) before July 30th, 2009

--------------------------------------GENERAL----------------------------------------
- Title :

- Last name:

- First name :

- Phone Number:

- Valid EMail:

- Adress 1 :

- Adress 2:

- Adress 3:

- Postal code:

- City:

- State :

- Country :

- Institution (full address):

- Student / Faculty / Industry ?

- Age: (optional, will help us managing the lodging)

--------------------------------------RESEARCH--------------------------------------
- Status :

- Research interests, relevant publications :

- Recommended by (for students) :

----------------------------------------POSTER---------------------------------------- Poster sessions will be organized. Do you wish to present work related to the general theme ? Tentative Title :

------------------------------RETURN_ADDRESS----------------------------------
By regular mail :
Delphine CHARBONNEAU
LOA - ESPCI, 10 rue Vauquelin - PARIS 75231 Cedex 05

By email at therapeutic.ultrasound@loa.espci.fr and on the generated page, please fill the form as follow:

 

 

 

 

 

 

 

 

 

 

 

By fax : 33 (1) 40 79 44 68