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\begin{document}
{\sc
\begin{center}
\begin{tabular}{lcr}
\begin{tabular}{c}
 {\Huge{\rm\bf B} V P}\\
{\Huge{\sc\bf F} E}\\
{\Huge\bf A}\\
Kraków, {\bf 2010}\\

\end{tabular}
& \multicolumn{2}{c}{\begin{tabular}{c}
{\LARGE {\bf B}oundary Value Problems}\\
{\LARGE {\bf F}unctional Equations}\\
{\LARGE and {\bf A}pplications}
\end{tabular}}\\
\hline \multicolumn{3}{c}{\rm\small Pedagogical University,
Department of
Mathematics, 2 Podchorążych Street, 30-084 Kraków, Poland}\\
{\rm\small {\bf e-mail}: bfa@ap.krakow.pl }&&{\rm\small {\bf
phone}: (48)(12) 662-62-76, 662-62-73 or 662-62-74}
\end{tabular}
\end{center}}
\vspace*{0.3in}


\begin{center}
{\bf REGISTRATION FORM - JANUARY 2010}\\
(Please print or type all the information)
\end{center}
\vspace{.3in}\par\noindent
{\bf Full name}: \dotfill\ \ \dotfill\\
\hspace*{1in}\makebox[2.5in]{\raisebox{1ex}{\scriptsize \it
surname}}
             \makebox[2.5in]{\raisebox{1ex}{\scriptsize \it first
name}}\vspace{.2in}
             \par\noindent
{\bf E-mail address}: \dotfill \vspace{.2in}
\par\noindent
{\bf Affiliation}:
\dotfill \vspace{.2in}
\par\noindent
{\bf Postal address}:\newline\hspace*{3cm}
\begin{tabular}{l}
\makebox[10cm]{\dotfill}\\[2ex] \makebox[10cm]{\dotfill}\\[2ex]
\makebox[10cm]{\dotfill}\\[2ex]
\makebox[10cm]{\dotfill}\\[2ex] \makebox[10cm]{\dotfill}\\
\end{tabular}
\vspace{.2in}
\par\noindent
\begin{tabular}{lllcrc}
I would like to {\bf take part in the  BFA} Workshop &
YES&\fbox{\raisebox{2ex}{\ \ \ }} & NO&\fbox{\raisebox{2ex}{\ \ \
}}\\[2ex]
I need {\bf meals and accommodation} &YES&\fbox{\raisebox{2ex}{\ \
\ }}&
NO&\fbox{\raisebox{2ex}{\ \ \ }}\\[2ex]
I insist on staying in {\bf single} room (at the extra cost)
&YES&\fbox{\raisebox{2ex}{\ \ \ }} & NO&\fbox{\raisebox{2ex}{\ \ \
}}
\\[2ex]
I am going to {\bf present a talk}& YES&\fbox{\raisebox{2ex}{\ \ \
}} & NO&\fbox{\raisebox{2ex}{\ \ \ }}
\end{tabular}
\vspace{.2in}
\par\noindent
on \dotfill\vspace*{2ex}\par .\dotfill
\par
\hspace*{2.5in}\raisebox{2ex}{\scriptsize \it (presumable title)}

\vspace{.25in}
\par\noindent
I would like to come with (accompanying person(s)):\vspace{2ex}\\
\hspace*{1cm}{\makebox[3.5in]{1. \dotfill}}\vspace{2ex}\\
\hspace*{1cm}{\makebox[3.5in]{2.
\dotfill}}\vspace{.4in}\par\noindent \hspace{9.5cm}Signature
\makebox[2in]{\dotfill}

\newpage
 \end{document}
