ISBIS4 REGISTRATION FORM
ONE-DAY WORKSHOP April 13 • ISBIS4 April 14 – 16, 2005 
	• Novotel Palm Cove Resort, Tropical North Queensland, Australia •	
REGISTRATION DEADLINES: February 4, 2005 & April 6, 2005
TO BE FAXED TO: (+420) 267 310 503 OR TO BE SENT AS AN ATTACHMENT TO
 milena@action-m.com 
or mailed to: Action M Agency, Vrsovicka 68, 101 00 Praha 10, Czech Republic
Last Name: 	First Name: 	MR/ms	
university / company: 	
FACULTY:  	DEPARTMENT:  	
Street:   	City:   	
ZIP CODE:  	Country:   	
Phone:   	Fax:  	
E-mail:   	http://   	
NAME OF accompanying PERSON (s):  	
Special needs (vegetarian, disabled etc.):  	
Date (time) of arrival:   	Date of departure:	No of nights:   	
 PAYMENT BY BANK TRANSFER	    YES	      NO		 By bank transfer:
 Payments may be made
in Australian dollars, US dollars,    Euros or Czech Crowns.   Please transfer the payment to the account most convenient for you. (Czech Republic, Komercni banka, Praha 10, Kubanske nam. 15,  account  name -  Milena Zeithamlova, Action M Agency)

 Swift Code: KOMBCZPP	
 ISBIS4 ONE-DAY WORKSHOP (from 10.00 on Wednesday, April 13, 2005)			
 REGISTRATION FEE: Early: by Feb 4 / Late: after Feb 4 / On Site: after April 6			
	AUD	EUR	USD	CZK			
 FEE:                     AUD 295/350/405             EUR 175/205/240
                                    USD 215/260/300              CZK 5650/6700/7750							
 ISBIS4 (from Thursday, April 14 - Saturday, April 16, 2005)			
 REGISTRATION FEES: Early: by Feb 4 / Late: after Feb 4 / On Site: after April 6			
 Member: *         AUD 340/400/450             EUR 200/235/265
                                     USD  250/295/330            CZK 6500/7650/8650							
 NoN-MEMBER:    AUD 390/470/520             EUR 230/275/ 305 
                                     USD 285/340/375             CZK 7500/8950/9950						
 Tax Invoice required	
 STUDENT:               AUD 160/210/260             EUR 95/125/155
                                     USD 120/160/195             CZK 3100/4100/5100					 AUD Account No:
35-2407770217/0100      
IBAN: CZ6301000000352407770217
EUR Account No:
7473400217/0100          
IBAN: CZ3601000000007473400217
USD Account No:
7498980297/0100        
IBAN: CZ8901000000007498980297
CZK   Account No: 
221442-101/0100       
IBAN: CZ0801000000000221442101	
 PARTNER PROGRAM: 
                                          AUD 195 / eur 115 / USD 145/ CZK 3750						
 Gala DINNER:             
                                     AUD 95 / eur 55 / USD 65 / CZK 1750						
 Gala DINNER for STUDENT:             
                                     AUD 50 / eur 30 / USD 35 / CZK 950						
 TOTAL:                   AUD / EUR / USD / CZK                                                  						
 * Please indicate to which SPONSORING SOCIETY or
 participating organiSation you belong to or if you are an INVITED SPEAKER		
 name of PAYER:	 date of payment:		
 name of bank:		
 PAYMENT BY CREDIT CARD ( in CZK only):	    YES	      NO	    YES	
VISA	MASTERCARD/EUROCARD	AMEX	JCB	DINERS CLUB	
																 Expiry date:	
 LAST 3 DIGITS:               				(on the signature strip -
the reverse side)	 CC HOLDER NAME:	
 I, the undersigned, authorise the Action M Agency to charge to my 

 credit card the total amount of ________________CZK	 CC HOLDER SIGNATURE: