Please, fill and send to:

CNRS - DR20
Agnes Moreau
Les Lucioles 1
250 Avenue Albert Einstein
06560 Valbonne
France

DO NOT SEND BY FAX

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    Credit Card Form


First name _________________   Last name ___________________

I authorize CNRS to debit my credit card :

|_| VISA      |_|  EUROCARD      |_| MASTERCARD

Card's number: |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|

Expiration date: |_|_|_|_|

Amount: |_|_|_|_| euros

Date: 

Signature :


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    CIAA 2005 Registration for (if not the card owner)

First name _________________   Last name ___________________


Institution ________________________________________________