America - Home of the Brave
Palacky University, Olomouc, Czech Republic , August 29 - September 3, 2004
APPLICATION FORM
Kindly return this form as soon as possible and no later than May 15, 2004 to:
Conference Centre of Palacký University, Mrs. Jitka Hýbnerová, Biskupské nám. 1,
771 47 Olomouc, Czech Republic, Tel.: *420-58-5631038, Fax: *420-58-5222802
(one for each individual, please make copies if necessary)

Title:	First name:	NAME:

	
Status (teacher, student, etc.)
	
Institution:

	
Address for correspondence:	
Street:

City: 

	Zip code:	
Country:

	Tel:
	
e-mail:

	Fax:	
Accommodation choice 
(Student housing)
Single room:  7 USD/night                            □
	
Double room:  10 USD/night                           □
 Shared with:

Arrival:
	Departure:	

Date:.........................................	                                 Signature:.......................................………