2014 UEMS ORL SECTION AND BORD MEETING October 02 - 05, 2014 Hotel Excelsior Dubrovnik, Croatia Welcome to Dubrovnik! REGISTRATION FORM Please complete this form and return it to SPEKTAR PUTOVANJA d.o.o., Tkalčićeva 15, Zagreb, Croatia T: +385 1 4862 606, F: +385 1 4862 622, e-mail: [email protected] PLEASE USE BLOCK LETTERS PARTICIPANT INFORMATION Family name:_______________________________________ First name:__________________________________ Title:__________________ Department/Institute/Hospital:__________________________________________________________________________________________ Address:_______________________________________________________________________________________________________________ Zip code: ___________________________________ City: ________________________________ Country: ___________________________ Phone: _____________________________________ E-mail: ______________________________ Fax: ________________________________ ACCOMPANYING PERSON □ Mr. □ Mrs. Family name:_______________________________________ First name: __________________________________ REGISTRATION FEE Delegate Accompanying person □ □ € 834 per person € 434 per person The congress registration fee includes: Delegate: 3 nights in single use room B&B from October 2 to October 5, 2014 Congress badge Scientific sessions and coffee breaks during the Meeting Get together dinner on October 2 Lunch and Dinner on October 3 and October 4 City tour on October 4 Accompanying person: 3 nights in shared double room B&B from October 2 to October 5, 2014 Congress badge Get together dinner on October 2 Lunch and Dinner on October 3 and October 4 City tour on October 4 Registration fees are in Euros and include VAT of 13% and city tax Important Registration will be confirmed upon receipt of payment. Deadline for registration and payment: September 10, 2014. After this date we cannot guarantee the availability. TOTAL TO BE PAID: ________________________________ TRANSPORTATION Transportation costs are not covered by the congress organizer. However, the Spektar agency can assist you in making the necessary travel arrangements. Please contact: [email protected] for assistance. □ I will take care of the transport reservation on my own. Do not forget to take into consideration your speaking times, prior to booking your travel. INVOICE INFORMATION □ All Symposium costs are covered by participant □ If you, as a participant, do not cover all the costs, kindly fill out the information of the company and mark which costs are paid by that company Company name: ________________________________________________________ VAT number:_______________________________ Address: __________________________________________________________________________________________________________ Zip code: _____________________________________ City: __________________________________ Country: ____________________ Phone: __________________________________________ E-mail: ________________________________ Fax: _____________________ □ Registration □ Transfer CANCELATION POLICY Cancellation is only possible in writing to the following address: Spektar putovanja d.o.o., Tkalciceva 15, 10000 Zagreb, Croatia All cancellations received by August 2, 2014 will be reduced for 25, 00 EUR / 190, 00 KN (administrative costs) After August 3, 2014 refund of 50% of paid registration will be made, reduced for 25, 00 EUR /190,00 KN for administrative costs After September 2, 2014 refund is not possible. Important: Spektar putovanja d.o.o. takes right to charge 25, 00 EUR / 190, 00 KN for changes and cancelations METHODS OF PAYMENT ■ By bank transfer: Bank transfer payment should be made to Spektar putovanja d.o.o. The participant's full name and the reference number 082/003/2014 should be included with the payment Account information for payment in KUNA: Account information for payment in EURO: Spektar putovanja d.o.o. Spektar putovanja d.o.o. ZAGREBACKA BANKA ZAGREB ZAGREBACKA BANKA ZAGREB IBAN HR3923600001101441264 IBAN HR1323600001500395457 SWIFT/BIC: ZABAHR2X ■ By credit card: The payments made by credit card will be in local currency Kuna and the EURO fee amount will be calculated according to the valid exchange rate on the day of the payment. O American Express O Diners Club International O Eurocard/MasterCard O Visa Credit card number Expiry date: Month ____________ / Year ____________ 3 digit security number (last three numbers in signature box): Authorization: Having signed below, I herewith confirm that I have read and I am fully aware of the cancellation conditions. I hereby authorize Spektar Putovanja to debit this credit card account for the total amount due, I also consent to Spektar Putovanja debiting or crediting my credit card account with the amount of any subsequent change(s) to the items booked. I also authorize to process my personal data due to conference purpose. I am aware that I may review and correct my data. Credit card owner’s name _________________________________________________ Signature _____________________________________________________ Date______________________________________________________ If you are interested in post-meeting tour, please contact [email protected]