Surname: ____________________________

Given Names: ____________________________

Place of work: ____________________________

Address of work: ____________________________

Place of residence: ____________________________

E-mail: ____________________________

Telephone number: ____________________________

State yes or no if you would like to:
1) participate ________________
2) give a presentation ________________

Language of your presentation: _______________________

The title of my presentation:

The abstract in English (max. 10 sentences, you can also mail it as an attachment):

For my presentation I required these materials and aids: _______________________

Date Signature