             SOFSEM 2001 - Workshop only Registration Form
             ---------------------------------------------

Please E-mail to   sofsem@dcs.fmph.uniba.sk
or mail/fax a signed copy to     

                   SOFSEM 2001,  
                   Attn. Mrs. M. Kozarova, INFOSTAT 
                   Dubravska 3 
                   842 21 Bratislava, Slovakia 

                   fax: (+421 2) 54 77 26 20, (+421 2) 54 79 14 63 


Given name:           ___________________    [] Mr.  [] Ms.

Middle initials:      ______________

Family name:          __________________

Affiliation: ______________________________________________________

Address:     ______________________________________________________

             ______________________________________________________
 
             ______________________________________________________

e-mail:      _____________________

fax:         _____________________

telephone:   _____________________


Type of Fee (S4,..., S8): ______

Single / Double Room: ___________

Vegetarian (Y/N):     _________

Expected Date of Arrival: __________________

Expected Date of Departure: __________________

Number of Additonal Nights: ___________
 
Amount Paid:          __________________ 

Date of Payment:      __________________

Details of Payment:   ___________________________________________


Special requirements: __________________________________________


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