5 th ADVANCED COURSE on endoscopic management of gastrointestinal and pancreatico-biliary neoplasia Course DirectoRS Pier Alberto Testoni Paolo Giorgio Arcidiacono REGISTRATION FORM please type or print in capital letters and send within August 31st to: FORMA Communications s.r.l. Via Chiaia, 149/E – 80121 Napoli Italy Fax +39 081 714 59 54 Email: [email protected] PERSONAL INFORMATION Prof Dr MD PhD Ms Mrs Ms Family name ________________________________________ First name _______________________________________ Date of birth (dd/mm/yyyy ) M F Payment must accompany each registration and be processed within the appropriate deadline. The total amount will be paid as follows: • Bank transfer To Forma Communications, Napoli - Banco di Napoli Account no. 1000 0000 1253 IBAN: IT29 L01010 03495 1000 0000 1253 Swift Code: IBSPITNA • Credit Card (charge 2% for payments by credit card) Institute Visa Department Mastercard No. Postal Address Postal code City Cardholder’s name Country CVV2 Code (last 3 digits in the signature field on your credit card) Tel. Fax Expiration date E-mail Date REGISTRATION FEES Registration fee € 427.00 VAT included • FREE Registration for under 35 participants • Discounted rate 20% for the following societies’ members: Signature DETAILS FOR INVOICE Name of Individual or Organization Postal Address • ESGE (European Society of Gastrointestinal Endoscopy) • SIED (Società Italiana di Endoscopia Digestiva) Postal code • AIGO (Associazione Italiana Gastroenterologi Ospedalieri) Country • SIGE (Società Italiana di Gastroenterologia ed Endoscopia Digestiva) • SIPAD Tel. (Società Italiana Patologia Apparato Digerente) Fax CME credit for Italian surgeons, gastroenterologists, oncologists, internists and radiotherapists The Congress registration fee includes: • Access to the Congress • Congress Kit • Lunch and coffee breaks • Certificate of Attendance City E-mail Vat number/tax code CANCELLATION POLICY Cancellations may be accepted if received within august 31st; 20% of the registration fee will be charged for administrative expenses. Requests for cancellation or refunds sent after august 31st will not be considered.