registration form

"Non-contraceptive impact of contraception and family planning"

APRIL 30 - MAY 3 2008 PRAGUE, CZECH REPUBLIC

ONLINE REGISTRATION

Personal details (*obligatory fields)

Participant

*Family/Last Name:
Prefix:
*First name:
*Title:
*Title for correspondence:
Institute:
Department:
*Street/Number:
*Post code:
*City:
*Country:
Tel:
Fax:
E-mail:

The above identification details may be used by the ESC for future mailings. Please place a tick in the box if you do NOT wish your name and address to be included in the following type of mailings:

Not ESC-related activities Company related information

Please note that you have the right to change and to look at the above personal information which is kept by the ESC at any time, by simple request.

Registration part (*obligatory fields)

*I am a member of the European Society of Contraception (ESC):

All payments are payable in Euro (registration fees: see page registration)

*I register for the Congress as:

* status must be evidenced by a written employer's statement or copy of certificate. (to be sent as an attachment to the Congress Secretariat: congress@contraception-esc.com)

I register for the Congress Dinner:

Extra persons (besides yourself) attending the Opening Ceremony and Cocktail:

*I have to pay a total amount of

euro. (please make your own calculation: all fees are mentioned on the page registration>>)

*I will pay as follows:

Note: for payment details such as bank account number as well as for cancellation policy see the respective details on the page with information about registration>>

Invoice name and address: (if different from participants address).

VAT number (if applicable):

	In case of creditcard payment (eurocard/mastercard/visacard only) fill out next details:
	(if you don't like to send your creditcardnumber through internet you can download the registration form -pdf.file- and send it by post to the ESC Central Office)
	You are allowed to charge my
	Card number:
	Card Verification Code:
	The Card Verification Code (CVC) is printed on your MasterCard & Visa cards in the signature area of the back of the card. (it is the last 3 digits AFTER the credit card number in the signature area of the card).
	Exp.date:
	Name of cardholder:

Note: after submitting this registration form you receive a confirmation of the registration with payment details to print out for your administration!

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