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EXTREME PHYSICS MEETING REGISTRATION FORM

PERSONAL AND GENERAL INFORMATION

TITLE

NAME

SURNAME

DATE OF BIRTH

Anno / Mese / Giorno

PLACE OF BIRTH Please specify City and Country

PERSONAL ADDRESS OF RESIDENCE

ZIP CODE

CITY

COUNTRY

PHONE NUMBER

E-MAIL ADDRESS

INSTITUTION/AFFILIATION/ORGANIZATION

DEPARTMENT

ADDRESS

ZIP CODE

CITY

COUNTRY

NOTE TO THE SECRETARIAT

PRIVACY POLICY - Informational statement according to article 13 of Legislative Decree 196/2003 (Code on protection of personal data) Information and personal data are collected through the voluntary compilation of the form and are used for the purpose of the participation to the Conference. The data collected can be memorized both in electronic and paper format and will be used by us respecting all the measures provided by law for the safeguarding of the rights of the interested parties.The giving of data is optional; possible refusal to provide this data could mean the inability on our part to send the information requested and process your registation to the Conference. Data will be used also with electronic devices and may be used for administrative, fiscal and/or commercial activity. We will not pas data to unauthorized third parties. Responsibility for the use of data is Consorzio Ferrara Ricerche, Via Saragat 1, 44122 Ferrara (FE). You should act for your right as stated in art. 7, by sending an e-mail to cfr@unife.it.

I HAVE READ AND AGREE WITH THE ABOVE STATEMENT

YES

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