REGISTRATION FORM

FOURTH INTERNATIONAL CONFERENCE ON SELENIUM IN THE ENVIRONMENT AND HUMAN HEALTH

October 18-21, 2015, Bourbon Convention Ibirapuera in São Paulo, Brazil

Please type or use block letters
PARTICIPANT

Prefix: Prof   Dr  Mr  Mrs  Ms

Fist Name:

Family Name:

Name on Badge:

Title/Position:

Affiliation:

Mailing Address:

City:State:

ZIP/Postal Code:Country:

Telephone:

E-mail:

REGISTRATION FEE

 Regular participant: $350 (USD) if the registration form is submitted prior to August 1, 2015

 Regular participant: $400 (USD) if the registration form is submitted after August 1, 2015

 Student participant: $200 (USD)

Note: The registration fee covers the book, welcome reception, meals,city tour, and conference banquet. Registration fee will be paid on site at the conference registration desk. Payment options include major credit cards or international bank draft.

PRESENTATION PREFERRED

The conference language: English

 Podium

 Poster

 None

VISA APPLICATION

An official invitation letter from the conference organizer

 Need

 No need

Nationality:

Passport Number:

ACCOMMODATION RESERVATION

Check-in date and time:

Check-out date and time:

Conference Hotel (Bourbon Convention Ibirapuera)

Room type

 One Queen Bed
 Two Twin Beds
 Single Bed
Estimated Nightly Rate (USD)

$114
$114-129
$104
Note: You can reserve your room(s) on-line by yourself (e.g.,
www.expedia.com) or through local conference organizers.

TRAVEL INFORMATION (if assistance needed)


Arrival date and time:

Flight number and airport:

Departure date and time:

Flight number/airport:

SOCIAL PROGRAM

A city tour and the conference banquet are scheduled on October 20, 2015.

 Attending

 Not Attending

Post-Conference Field Trip to Fazenda AruanПлк Brazil Nut Farm in Manaus, Amazonas (October 21-22, 2015)

 Attending

 Not Attending

Accompanying Person(s)

 Yes        How Many:

 No



Note: The cost of the conference reception and banquet for each accompanying person is $50 (USD).