MUST FAX OR MAIL THIS FORM TO COMPLETE REGISTRATION

ECRYPT NoE CRYPTANALYSIS SUMMER SCHOOL  MAY 9-13  2005

Pythagorion, Samos, Greece

REGISTRATION FORM

Please complete the sections below. Please print clearly and in CAPITALS.

To register, either:

- Fax the completed registration form with credit card information to +32 16 32 19 69.

- Send the completed registration form with payment information to:

Pela Noe
ESAT/SCD-COSIC
Kasteelpark Arenberg 10
3001 Heverlee

Belgium

1. PERSONAL INFORMATION

Title/First Name/Last Name : __________________________________________________

Company/Organisation: ______________________________________________________

Mailing Address: ____________________________________________________________

Phone : __________________________   Fax : ________________________

E-Mail : ________________________________________

2. REGISTRATION FEE (check applicable category)

O Student Registration (€225)                         O Non-student registration (€275)

Registration includes participation in the workshop, course material, lunches and coffee breaks from Monday to Friday, and the course dinner on Thursday evening.

3. SPECIAL NEEDS

Any physical or dietary needs : _________________________________________________

_________________________________________________________________________

4. PAYMENT

Payment must accompany your  registration form. Only payment in euros are accepted.

O Charge the registration fee (€ _____)to the following  credit card:

            O Mastercard              O Visa

Card Number: __________________________  Expiry Date : ________________________

Card Holders Name: __________________                                     Card Holder’s signature: