-------------------------------------------------------------------------------- Please note that in the registration form below, a misleading formulation found within the original form was clarified. Basic accommodation is INCLUDED in the registration fee. Unless shared accomodation has been requested, the accomodation provided is single person in a double-bed room. No extra accomodation cost is therefore required for one accompanying person. If more rooms are needed, please add the accomodation cost for each double room requested. The registration fee includes breakfast and lunch for participants of the conference. Additional breakfasts and/or lunches for accompanying persons can be oredered at the conference registration desk during the conference. -------------------------------------------------------------------------------- REGISTRATION FORM GOEDEL'96 LOGICAL FOUNDATIONS OF MATHEMATICS, COMPUTER SCIENCE AND PHYSICS August 25-29, 1996, Brno, Czech Republic IMPORTANT * Completed registration forms should NOT be e-mailed. Paper copies should be sent to the correspondence address (at the bottom of this form). * The registration form can only be accepted if accompanied by full payment. * One participant per registration form. REGISTRATION DETAILS: Prof/Dr/Mr/Mrs/Ms/Miss: _______________________________________ Surname: ____________________________________________________ Given Name: __________________________________________________ Position/Title: _______________________________________________ Department: __________________________________________________ Organisation: _________________________________________________ Address: ______________________________________________________ State: _______________________________________________________ Postcode: ____________________________________________________ Country: _____________________________________________________ E-mail: _______________________________________________________ Business Telephone: (_____) ____________ Fax: (____) __________ Preferred Name for Badge: _____________________________________ SPECIAL REQUIREMENTS: Special Diet: ________________________________________________ Other: _______________________________________________________ ACCOMMODATION: Please indicate if required (tick): ( ) University guest hotel Accomodation Type: ( ) Single Person in Double Room (no sharing) - $20 for one night $20 per night; five nights INCLUDED in registration fee From: __________ To: ___________ # of nights: ________ Insert only ADDITIONAL cost for extra nights: TOTAL : $ ________ ( ) Double (2 sharing one room) $50 for one person sharing a room for 5 nights From 25.8. to 29.8. (5 nights) : $50 Room sharing prefered with: ___________________ Sorry -- no additional nights can be guaranteed. ( ) Reduced full-time student conference fee -- accomodation for four night included in the reduced fee package, see below. ( ) Hotel *** "Continental" Reservation required: From: __________ To: ___________ # of nights: ________ Price approx. $70 per night. Reservation required before June 1, 1995. Payment details will be sent separately. DEDUCT $100 from your registration fee when choosing this. Arrival: Departure: Arrival time: REGISTRATION FEES Received Received TOTAL by after 21/3/1996 21/3/1996 Members of ( ) KGS, ( ) ASL, ( ) EACSL, ( ) IUHPS/DLPMS, ( ) CSIS (tick one) indicate membership number: _________________ Conference Fee $350.00 $380.00 $ _______ Conference Fee shared room $300.00 $330.00 $ _______ Conference Fee without accom. $250.00 $280.00 $ _______ Others: Conference Fee $380.00 $400.00 $ _______ Conference Fee shared room $330.00 $350.00 $ _______ Conference Fee without accom. $280.00 $300.00 $ _______ Full-time student package: Reduced conference fee covering conference attendance and five nights in shared room: $140.00 $190.00 $ _______ Reduced student fee does not include conference proceedings copy. Attach written statement your university certifying your full-time student status. Excursion: $30 per person; # of persons: _________ TOTAL: $ ________ TOTAL TO BE PAYED.......................................... USD $ ________ METHOD OF PAYMENT (All payments in US dollars) ( ) A Credit Card Tick Card Type: ( ) VISA ( ) MC/EC Card no. ________________ Expiration ____/____ Cardholder's Name: ________________________________ Cardholder's Signature ______________________________ ( ) B Bank Cheque/Eurocheque payable in US dollars to "Faculty of Informatics, Masaryk University" (enclosed) ( ) C Bank transfer to: Bank: Komercni banka Praha, branch Brno Account holder: Masaryk University Account Number: 85 636-621/0100 Date of transfer: (copy of bank transfer confirmnation enclosed) Send completed form with you payment to the following address: Dr Jiri Zlatuska GOEDEL'96 Faculty of Informatics, Masaryk University Botanicka 68a, CZ-602 00 Brno, Czech Republic ------------------------------------------------------------------- A limited number participants from economically severely handicapped countried can be supported by the organizers by allowing registration for student fee. Send your application for financial assistance electronically to, or to the above address, if electronic connection cannot be used.