68th PSSL/MFCS Registration Form (e-mail)
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I want to attend the 68th PSSL in Brno

Name:

Address:

email:

I wish to give a talk entitled:

I wish to have the PSSL accommodation and meals:

Special dietary requirements: __________________


Method of payment (all payment in US dollars):
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     [] VISA      [] MASTERCARD    [] EUROCARD 

        Please note that the amount your card will be charged depends on
        the actual change rate. 
        Please make signed this Registration Form and send it to

                   Faculty of Informatics MU
                   MFCS, Jan Staudek
                   Botanicka 68a
                   602 00 Brno, Czech Republic       


        Amount to be payed: ________________

        Cardholder's name:  ----------------

        Card no.: _________________  Exp: __/__/__ 


       Sign:_____________________

     [] Bank Checque / Eurochecque

        Please make check payable in US dollars to 
        "Faculty of Informatics, Masaryk University" enclosed to
        signed this Registration Form and send all to

                   Faculty of Informatics MU
                   MFCS, Jan Staudek
                   Botanicka 68a
                   602 00 Brno, Czech Republic


       Sign:_____________________

     [] Bank transfer to      Komercni banka, a.s.
                              pobocka Brno-mesto
                              nam. Svobody 21
                              631 31 Brno, Czech Republic

               SWIFT Code:     KOMBCZPP
               Account Number: 85636621/0100
          Account Number:      1234567890-1234567890
          Details of Payment
               (Mandatory):    3375000498, < name >

          Be sure to clearly state 3375000498 and your name 
          in Details of Payment.

          Amount of Payment :  $ __________  

          Amount of Payment :  __________  Kc

                For Czech participants 
                (in accordance with current currency rate) 

          Expected Date of Payment : ------------

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