WORKSHOP ON COMPUTATIONAL PHYSICS

DEDICATED TO THE MEMORY OF STANISLAV MERKURIEV

Registration Form

1

  Family name:

2

  First name(s):

3

  Citizenship:

4

  Country of permanent residence:

5

  Degree, title(s):

6

  Affiliation:

7

  Position:

8

  Mailing address:

9

  e-mail:

10

 Phone(s):

11

  Fax:


 If you need visa fill in the following fields as well:

12

  Date of birth:

13

  Place of birth:

14

  Passport number:

15

  Passport date of issue:

16

  Passport date of expiry:

17

  City (with a Russian  Consulate) where you will apply for a visa:

18   FAX number to send the invitation to:
19   Mailing address to send the invitation to:
20   I would like to visit the cities:
   
IMPORTANT: please fax to: + 7 (812) 234 58 19 ( for Elena Novikova) a copy of two adjacent pages of your passport which contain your photo, passport number and expiration date  
 Do likewise with the passports of all accompanying persons 

I would like to come 
with accompanying person(s):

yes no

 Their names:
 If "yes", please fill in the same fields 1-20 for every of them (please DO NOT omit affiliation, position, address and fax of the institution FOR EMPLOYED and FOR STUDENTS or PUPILS) 

IMPORTANT: Please, check that your medical insurance is valid in Russia.


I need a hotel:                  yes no

Date of arrival:

Date of departure:

If possible, please provide the details about the type of room you wish and the persons you wish to share the room with :
number of rooms: Click on arrow and choose from the list
shared with:
price per apartment:
number of persons: Click on arrow and choose from the list

 

To submit the form, please press "SUBMIT" button or e-mail it to: admin@euler.pdmi.ras.ru

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