VI. TRANSFUZIJSKI DANI
22.-24. RUJAN 2011., ZADAR
PRIJAVNICA / REGISTRATION FORM
(prijave za simpozi se primaju do 10. rujna 2011.)
(as the number of participants is limited, registrations are accepted until 10 of September 2011.)
Molimo Vas prijavu ispunite elektronski ili tiskanim slovima i pošaljete putem e-maila ili faxa na
kontakt:
We are kindly requesting you to fill in the application form on your computer or in print letters and
send it by e-mail or fax to the following contact:
T.M.D. TRAVEL d.o.o.
HR-10000 ZAGREB, Horvaćanksa 27
IDK: HR-AB-01-080458509
Fax: +385 (0) 1 3014 012
e-mail: [email protected]
SUDIONIK/ PARTICIPANT
Titula / Title
Ime/Name
Prezime/Family name
Ustanova, tvrtka/Hospital, company
Adresa / Address
Poštanski broj
Grad
Država
Telefon
Fax
E-mail
Pratitelj / Accompanying person
Ime/Name
KOTIZACIJA / REGISTRATION FEE
Specijalisti/Specialists: 1000 kn
Prezime/Family name
Specijalizanti/Interims: 500 kn
Ostali/Others: 500 kn
Molimo rezervaciju smještaaj u /Please make accommodation in:
HOTEL KOLOVARE, 4****, 22.09. večera – 24.09. ručak
Jednokrevetna soba / Single room Kn 1.490 - 2 puna pansiona
Dvokrevetna soba / Double room Kn 2.380 - 2 puna pansiona za 2 osobe,
Način dolaska / Arrival:
Organizirani-autobusom / organized by bus
Zagreb – Zadar – Zagreb
Kn 350 po osobi
Vlastiti prijevoz / Own transportation
U K U P N O: Kn _________________________
Sudjelovanje ću platiti / I will pay the participation by:
Virmanom / Bank transfer
Gotovinom /Cash
2484008-1101666380 RBA Zagreb
IBAN: HR3924840081101666380
SWIFT: RZBHHR2X
UPLATITELJ, SPONZOR
Ustanova, tvrtka/Hospital, company
Kontakt osoba
Mastercard
Broj kartice______________________
Vrijedi do _______________________
Nositelj
Uplatitelj, sponzor
UU

Bolnički transfuzijski odbor