REGISTRATION FORM
of participant of the Fractals and Modern Mathematics Conference
24th December 2009
Kyiv, Ukraine

Last name _______________
Name _______________
Patronymic name _______________
Academic degree _______________
Affiliation ______________________________
Position _______________

Mailing address ______________________________
Phone working _______________
      home _______________
Email _______________

Title of the talk ______________________________
(+) I shall give a talk on the conference
(_) I shall be present on the conference but shall not give a talk

During the talk, I need
(_) beamer
(_) overhead projector
(_) black board and chalk

[_] I shall participate in the conference dinner and shall pay 200 UAH on arrival