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Biophotonics

Vitesse Interdisciplinary Workshop
Biology for Biophotonics
February 22 - 25, 2005

Registration Form

PERSONAL DATA

#1 Title

#2 First Name

#3 Last Name

#4 Institution

#5 Position

#6 Address

#7 City

#8 Province

#9 Postal Code

#10 Telephone (Work)

#11 Telephone (Home)

#12 Fax

#13 E-mail

COURSE FEE

#14 Registration Fee
(Note: Early Bird Discount ends February 10^th,2005)

PAYMENT INFORMATION

#15 Payment Method

Please choose a method of payment:

Cheque (made payable to: Vitesse Re-Skilling Canada Inc.)

Visa

MasterCard

Amex

Cheques can be mailed to the following:
Vitesse Re-Skilling^TMCanada Inc.
1200 Montreal Road, Building M-50, IPF
Ottawa, ON K1A 0R6
Attn: Annalisa Garbe

Note: You will only be registered upon receipt of cheque.

If you are paying by credit card, you will be contacted by telephone for credit card information.