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{\Huge \bf WCC'99} \hfil
{
\begin{tabular}{c}
{\bf Workshop on Coding and Cryptography} \\
\sl Paris, January 11-14, 1999
\end{tabular}} \hfil
\fbox{\begin{minipage}{1.35in}\small Reserved to staff\\N$^{\circ}$\end{minipage}}

\begin{center}
  {\Large \bf REGISTRATION FORM}\\ \em Please return to Claudie
  Thenault (Secr\'etariat WCC'99), INRIA Rocquencourt, Relations
  Ext\'erieures, \\BP 105, 78153 Le Chesnay Cedex, France. Fax: +33 1 39
  63 56 38 -- Email: symposia@inria.fr
\end{center}

Name \dotfill First Name \dotfill Company \dotfill \smallskip

Address \dotfill \smallskip

.\dotfill \smallskip

Zip Code \dotfill City \dotfill \dotfill Country \dotfill \dotfill \smallskip

Tel \dotfill Fax \dotfill Email \dotfill

\paragraph{Registration Fees} (VAT 20.6\% included) -- Check the
corresponding box.\\
\begin{tabular}{lccl}
& Prior December 4, 1998 & After December 4, 1998 \\
\cline{2-3}
Participants & 2500FF \checkbox & 2800FF \checkbox \\
University members & 1200FF \checkbox & 1500FF \checkbox \\
Students$^{*}$ & \multicolumn{2}{c}{800FF \checkbox}
\end{tabular}

\bigskip

These fees include the conference attendance, the conference
proceedings, the lunches of Monday 11, Tuesday 12 and Wednesday 13,
the coffee-breaks, the welcome cocktail on Sunday 10 and the
participation to the banquet on Tuesday 12.

\smallskip

{\sl Banquet}: indicate the number of {\bf additionnal} persons:
\ldots{} (payment on site 215FF)

\smallskip

$^{*}$ {\em Students should enclose a photocopy of their 1998-1999 student card.}

\paragraph{Payment.} All payment should be made in French
currency payable to {\bf ``L'agent comptable de l'INRIA''}.

\smallskip
Registration forms without payment or order form enclosed will not be considered. 

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\item {\bf By bank check}\\
Please find enclosed a check of: \begin{minipage}{25mm} ~~~\dotfill ~FF \end{minipage}

\item {\bf By bank transfer to}\\
TR\'ESORERIE G\'EN\'ERALE DES YVELINES, 16 avenue de St Cloud, 78018 Versailles Cedex\\
Account N$^{\circ}$ 10071-78000-00003003958-80 \\
State your name and the conference reference: WCC'99

\item {\bf By credit card.} This payment is possible by
  correspondence. Please fill in the following lines.

Cardholder: Name \dotfill First Name \dotfill \smallskip

\checkbox I authorize INRIA to charge my credit card \hspace*{\fill}
\checkbox Visa \hfill \checkbox Mastercard \hfill \checkbox
Eurocard \hspace*{\fill} \smallskip

Card number 
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\ Expiration date
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\ Amount \dotfill ~FF
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\paragraph{Cancellation.}
Fees will be returned in full for any written cancellation received
before December 30th. No refund will be made in respect of
cancellations received after this date.

\paragraph{Train discount.} Please send me a SNCF railway discount
voucher (20\%) ~~ \checkbox

\paragraph{Special diet:} \makebox[4cm]{\dotfill}

\bigskip

\hspace*{\fill} {\bf Date:} \hfill {\bf Signature:} \hspace*{\fill}

\end{document}


