PRIJAVA ZA SUDJELOVANJE I HOTELSKI SMJEŠTAJ REGISTRATION & ACCOMMODATION FORM Molimo ispunite prijavu i pošaljite na: SPEKTAR PUTOVANJA d.o.o., Tkalčićeva 15, 10000 Zagreb, Hrvatska, T: +385 1 4862 611 F: +385 1 4862 622, E: [email protected] Please complete this form and return it to: SPEKTAR PUTOVANJA d.o.o., Tkalčićeva 15, 10000 Zagreb, Croatia, T: +385 1 4862 611 F: +385 1 4862 622, E: [email protected] Molimo Vas da koristite velika tiskana slova_Please use block letters INFORMACIJE O SUDIONIKU_PARTICIPANT INFORMATION Prezime_Family Name ................................................. Ime_First Name ..................................................... Titula_Title ........................ Ustanova/Institucija/Bolnica_Department/Institution/Hospital .............................................................................................................. Profesija_Profession .............................................................................. Adresa_Address ...................................................................... Poštanski broj_Zip Code ......................................... Grad_City ................................ Država_Country ..................................................... Telefon_Phone ..................................... E-mail_E-mail .............................................................. Faks_Fax .............................................. KOTIZACIJA_REGISTRATION FEE KATEGORIJA CATEGORY RANA DO 10.05.2015. EARLY TILL MAY 10th 2015 KASNA OD 11.05.2015. DO 28.05.2015. LATE FROM MAY 11th TILL MAY 28th 2015 U VRIJEME ODRŽAVANJA SIMPOZIJA_ON-SITE Dr.med., specijalist 750,00 kn 800,00 kn 850,00 kn Dr.med., specijalizant/student 450,00 kn 500,00 kn 550,00 kn Ostali 800,00 kn 850,00 kn 900,00 kn Kotizacija uključuje: Tiskane materijale Simpozija Pristup predavanjima i izložbenom prostoru Kave tijekom stanki Registration fee includes: Printed materials Admission to all Symposium sessions and Exhibition area Coffee during breaks SMJEŠTAJ_ACCOMMODATION HOTEL HOTEL JEDNOKREVETNA SOBA SINGLE ROOM DVOKREVETNA SOBA DOUBLE ROOM 742,00 kn 927,50 kn Hotel Dubrovnik 4* Osoba u pratnji u dvokrevetnoj sobi/ Accompanying person in DBL room: ................................................................................................. Datum dolaska/ Arrival date : ............................................... Datum odlaska/ Departure date : ............................................... Cijene smještaja izražene su po sobi/danu te uključuju noćenje/doručak, PDV i boravišnu pristojbu. Za mogućnost rezervacije drugih datuma za smještaj molimo kontaktirati [email protected] Rates are per room per day and include bed&breakfast service, VAT and city tax. For reservations before and after the Symposium dates, please contact [email protected] Important: Accommodation will be confirmed upon receipt of the payment. UVJETI OTKAZIVANJA SMJEŠTAJA Otkazivanje je moguće jedino pismenim putem na adresu Spektar putovaja d.o.o., Tkalčićeva 15, 10000 Zagreb Za sve otkaze smještaja zaprimljene do 15.05.2015. izvršiti će se povrat od 50% uplaćenog iznosa za hotelski smještaj + 180,00 kn za administrativne troškove. Nakon 15.05.2015. povrat nije moguć. CANCELATION CONDITIONS All cancelations must be sent in writing to Spektar putovanja d.o.o., Tkalčićeva 15, 10000 Zagreb, Croatia th For all cancelations received before May 15 , 2015 a refund of 50% of the registration fee minus handling fee of 25 EUR will be made th After May 15 , 2015 there are no refunds. INFORMACIJE ZA RAČUN_INVOICE INFORMATION Sve troškove Simpozija snosim sama/sam / I will cover all Symposium expenses by myself □ Pravna osoba/frima snosi sve ili djelomične troškove / Institution/Company will cover all or some Symposium expenses □ Pravna osoba snosi troškove za / Institution/Company will cover following expenses: Kotizacija / Registration fee □ Hotelski smještaj / Hotel accommodation □ PODACI O PRAVNOJ OSOBI / INSTITUTION/COMPANY DETAILS Tvrtka / Company .......................................................................... OIB/ VAT................................................................................. Adresa / Address ........................................................................................................................................................................... Tel ......................................................................... Email............................................................................................................. NAČIN PLAĆANJA_METHOD OF PAYMENT • • • • • Plaćanje je potrebno izvršiti unaprijed u kunama u korist agencije "Spektar putovanja" d.o.o. Bankovna uplata na žiro račun agencije Spektar putovanja, s naznakom naziva događaja, imenom i prezimenom sudionika te pozivom na broj 018/003/2015 Kreditna kartica offline: American Express, Diners, Eurocard/Mastercard, Visa Prilikom online prijave na ovoj internet stranici i odabira plaćanja kreditnom karticom offline preuzeti ćete offline obrazac za autorizaciju kreditne kartice. Ispunjeni obrazac šalje se mailom ili fax-om organizatoru kongresa. Kreditna kartica online: American Express, Diners Prilikom online prijave na ovoj internet stranici i odabira plaćanja kreditnom karticom online, biti ćete preusmjereni na sigurnu (128-bit SSL enkriptiranu) T-com PayWay stranicu gdje će se obaviti online plaćanje. Gotovina na blagajni Spektar putovanja, Tkalčićeva 15, 10000 Zagreb, Hrvatska Broj žiro računa za uplate u kunama Spektar putovanja d.o.o. ZAGREBACKA BANKA ZAGREB IBAN HR3923600001101441264 • • • • Payment should be done in advance, in kuna, on the account of agency Spektar putovanja d.o.o. Bank transfer - bank transfer payment should be made payble to Spektar Putovanjad.o.o. The participant's full name and the reference number 018/003/2015 should be included with the payment. Credit card offline: American Express, Diners, Eurocard/Mastercard, Visa For the credit card offline payment, please download the authorization form, which, after filled in, should be sent by mail or fax to the technical organizer Spektar putovanja. Credit card online: American Express, Diners For the credit card online payment you will be redirected to the secure T-com PayWay web page (128-bit SSL encripted), to finalised your payment. Cash at Spektar putovanja, Tkalčićeva 15, 10000 Zagreb, Croatia Account information for payment in EUR Spektar putovanja d.o.o. ZAGREBACKA BANKA ZAGREB IBAN HR1323600001500395457 SWIFT ZABA HR 2X
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