REGISTRATION / REPLY FORM

BLOCK CAPITALS PLEASE

First Name/Last Name:

Institution/Company:

Mailing address:

Postal / Zip Code: City:

Country: E-mail:

Phone: Fax:

• I wish to register and will pay the following registration fee.

DATES                                    FEE (U$)
Jan 01, 1999 - Mar 31, 1999     320,00
Apr 01, 1999 - Jun 30, 1999     360,00
Jul 01, 1999 - Sep 20, 1999       380,00
on site                                        400,00

• I am interested in attending the Congress and would like to be included in the Congress mailing.
• I am interested in exhibiting during the Congress and would like to receive further information.
• I am interested in supporting the Congress as a sponsor and would like to receive further information.

PAYMENT FOR FOREIGNERS:

• Check in US$ Dollars, payable in the U.S.A.
• Credit Card: • VISA • DINERS • MASTER CARD
• Card number: | _|__|__|__| |__|__|__|__| |__|__|__|__| |__|__|__|__|
• Expiry date: ____/____

I hereby authorize the debt of the registration fee as indicated above.

______________________________________________        Date___/___/___
Signature

When paying by credit card, name and signature must be the same as on the card. Please return the completed form to the Congress Secretariat.

INTERLINK / HOMEO 99
Rua Teixeira Leal, 107-A, Graça Salvador, Bahia, Brasil
Tel.: +55-71-336-5644 Fax: +55-71-3365633

In case of additional colleagues also interested in attending, please duplicate this registration form.