Scheda di iscrizione - Fiche d’inscription - Application form - Anmeldung

Ho intenzione di partecipare al colloquio.

Vi prego di inviare ogni ulteriore informazione al seguente indirizzo:

J’ai l’intention de participer au colloque.

Je vous prie de m’envoyer tout renseignement complémentaire à l’adresse suivante:

I wish to attend the colloquium. I request all information to be sent to this address:

cognome _____________________________________________________

(Nom de famille/ Surname/ Familienname)

nome ________________________________________________________

(Prénom/ Forename/ Vorname)

indirizzo ______________________________________________________

(Adresse/ Address/Adresse)

Città _________________________________________________________

(Ville/ Town/ Stadt)

Paese ________________________ Codice postale ____________________

(Etat/ State/ Staat) (Indicatif postal/Postal code/Post-kode)

Telefono _______________ Fax ______________ E-mail _______________

(Téléphone/Telephone/Telephon)

cognome __________________________ nome ______________________

(Nom de famille/ Surname/ Familienname) (Prénom/ Forename/ Vorname)

dell’ (degli) accompagnatore (i)/ de la (les) personne (s) d’accompagnement/

of accompanying person (s)/ einer/von Begleitpersonen

Desidero inoltre presentare una comunicazione sul seguente argomento:

De plus, je souhaite présenter un exposé qui portera sur l’argument suivant:

In addition, I would like to give a lecture on the following subject :

_____________________________________________________________

_____________________________________________________________

In/ en/in ____________________________ Lingua/Langue/Language/Sprache

__________________

Data/ Date/ Date/ Datum

______________________________

Firma/ Signature/ Signature/ Unterschrift

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