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ADVANCED COURSE on endoscopic management of

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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.
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