online registration 10th seminar

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REGISTRATION FORM

10TH SEMINAR OF THE EUROPEAN SOCIETY OF
CONTRACEPTION AND REPRODUCTIVE HEALTH

Belgrade, Serbia,  18 – 19 September
2009


1. Participant (*obligatory fields)

*Family name:
*First name: 
*Title: 
*Title for correspondence:
Institute:


Department:
*Street/Number:

*Zip code:

*City:

*Country: 
Tel:


Fax:
E-mail:
Date of birth: 

2. Registration
 (*obligatory fields)
(- ESC membership 2009 included in
registration fee-)

*I am a member of the
European Society of Contraception (ESC):
*I register for the Seminar as: 
I would like to attend the Seminar Dinner on
Friday 18 sept 2009 		 Please place a tick in the box if you
want to participate
3. Method
of payment (*obligatory fields)
*I pay as
follows:
In case of
creditcard payment (eurocard/mastercard/visacard only) fill
out next details:
(if
you don’t like to send your creditcardnumber through internet
please print out the pdf
registration file or word
(.doc) file and send it to the ESC Central Office by
mail or fax) 

You
are allowed to charge my
Card number:
Exp.date:
Name of cardholder:
I am willing to
send my signature  in writing to the ESC Central Office
if requested by my creditcard company: In that case you will be informed through the ESC
Central Office.
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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