HEALTH ECONOMETRICS WORKSHOP
4th – 6th DECEMBER 2008, UNIVERSITÀ DI MILANO – BICOCCA
CRISP • UNIVERSITÀ DEGLI STUDI DI MILANO - BICOCCA • UNIVERSITÀ DEGLI STUDI DI BERGAMO
UNIVERSITÀ DEGLI STUDI DI CHIETI - PESCARA • UNIVERSITY OF LEICESTER
WORKSHOP WEBSITE: www.le.ac.uk/economics/healtheconometrics/index.html • www.crisp-org.it
This form should be completed and returned by fax or e-mail to the local organising committee:
Dr. Stefano Rizza Fax: +39 02 70056 9114 • E-mail:
Via Bicocca degli Arcimboldi, 8 • 20126 Milano • Tel. + 39 02 6448.5841
PERSONAL DETAILS
Surname/Family name: ______
First/given names: ______
Title (Dr, Mr, Mrs, Ms, Miss, etc): ______
Date of birth: ______
Sex (male or female): ______
Nationality: ______
Country of birth: ______
Country of residence: ______
ADDRESSES
Permanent home address: ______
Address for correspondence (if different): ______
Postcode: ______Nation: ______
Tel: ______Fax: ______Email: ______
UNIVERSITY / RESEARCH CENTRE ______
DEPARTMENT ______
INVOICE DETAILS
Name: ______
VAT number (if any): ______
Codice Fiscale (Italians): ______
Address: ______
Postcode: ______Nation: ______
Chosen method of payment (tick): c ON-LINE BANKING c DIRECT TRANSFER
· The Registration fee for the conference is € 360,00 (£280)
· Late Registration fee (after October 15th) is € 420,00 (£330)
The registration fee covers attendance at all sessions, lunches, morning and afternoon coffee breaks, and conference dinner on Friday night.
The workshop organisation, according with Università degli Studi di Milano-Bicocca, is happy to accept payment either by on-line banking (credit card) or direct transfer.
c ON-LINE BANKING
From the website
https://scrigno.popso.it/PagoFacile/servlet/SeBenvenuto
· select language and enter as “anonymous user”
· click “unscheduled payment”
Details of bank order
· beneficiary: select “UNIV. STUDI MILANO - BICOCCA”
· type of payment: select “HEALTH ECONOMETRICS WORKSHOP”
· then fill “Information payer”
· amount in EURO only: € 360,00. (after October 15th is € 420,00)
· reason: write “Health Econometrics – your surname”
c DIRECT TRANSFER
BANCA POPOLARE DI SONDRIO
Agenzia di MILANO - AG. n. 29 Bicocca. Piazza della Trivulziana, 6 - 20126 Milano
IBAN : IT87 K056 9601 6280 0000 0200 X71
BIC/SWIFT code of the bank: POSOIT22XXX
reason: “Health Econometrics - your surname”
CRISP • Università degli Studi di Milano Bicocca • Università degli Studi di Bergamo
Università degli Studi di Chieti - Pescara • University of Leicester
______