EBHA 2004 Conference - Registration

Personal details

Title: First name: Last name:

Position: Affiliation (University, etc.):

Contact details

E-mail: Fax:

Contact telephone: -

Address

Please put the address which you want to appear on the receipt for your registration fee.

Institution (if applicable):

Street and number:

Postcode: Town: Country:

	Choices for lunch

	Friday 17 September 2004 Breast of chicken in cream of mushroom sauce Grilled salmon supreme served with seasonal vegetables

	Saturday 18 September 2004 Beef entrecôte served grilled or with green pepper sauce Hake supreme served Bilbao style

	Calculation of conference fee

	Please note that the discount for early registration before 1 July 2004 will be calculated automatically. (If we do not receive your payment by 15 July 2004, we will ask you to pay the difference upon registration at the conference venue.)

	I am a registered member of the EBHA for 2004 (If not, please join the EBHA before registering) I am a graduate student (Please not that you will have to provide proof of your status upon registration at the conference venue)

	Accompanying persons: I would like to receive additional tickets for the reception and conference dinner (at 50 € each)

	Fee to pay: €

Method of payment

Billing Address:

I will transfer the fee of € to the EBHA2004 Bank account:

- IBAN ES30 0182 5734 3302 0150 7022

- SWIFT BBVAESMMXXX

- Account holder: Institut d'Educació Contínua - EBHAN 2004

- Bank: BBVA, Plaça Catalunya 5, 08002 Barcelona


	Important: Please note that 6 € are added to cover the transfer fee charged by our bank. Please make sure that your bank accepts all the fees on your side. Otherwise, we will have to charge you the difference upon registration at the conference venue.

Please charge the fee of € to my credit card:

	Type of card: Card number: (16 digits - no spaces)
	Expiry date: -
	Name of the cardholder (as it appears on the card):