close

Вход

Log in using OpenID

ADVANCED COURSE on endoscopic management of

embedDownload
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.
Author
Document
Category
Без категории
Views
15
File Size
350 Кб
Tags
1/--pages
Пожаловаться на содержимое документа