9th Ibero-American Workshop on Complex Fluids
and
2nd Italian-Brazilian Workshop on Liquid Crystals

14th to 18th October 2013, Maceió - Brazil

WORKSHOP REGISTRATION FORM

Family name and first name:	
	
Affiliation:	
	
Function:	

Address:	
	
Postal code and town:	
	
Country:	

Telephone:	
	
Fax:	
	
E-Mail:	
	
Special requirements (vegetarian etc.): 

Payment Agreement

I agree to pay the registration fee on-site (US$ 200.00 - regular, US$ 100.00 - students) by 15th October 2013

Signature:                                                            Date:           /          /          /                                                       

* This price includes workshop fee, lunches and workshop documents etc.  Accommodation and evening meals costs are not covered by this fee.	
	
Please E-MAIL this form to Italo N. de Oliveira at Universidade Federal de Alagoas, Maceió-AL, Brazil
	E-MAIL:iberoFCx@fis.ufal.br

CONFIRMATION OF YOUR REGISTRATION WILL BE SENT BY EMAIL