online registration 8th ESC congress

REGISTRATION FORM

8^TH CONGRESS OF THE EUROPEAN SOCIETY OF

CONTRACEPTION

Edinburgh, Scotland, UK 23-26 June

2004

Personal details (*obligatory

fields)

Participant

*Family/Last Name:
Prefix:
*First name:
*Title:
*Title for correspondence:
Institute:
Department:
*Street/Number:
*Zip 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.

Accompanying person

Mrs/Ms/Mr:
Family/Last Name:
First name:
Remarks (if any p.e. names of additional accompanying persons):

Registration

part (*obligatory fields)

*I am a member of the

European Society of Contraception (ESC):

All

amounts are payable in Euro (registration fees: see

page registration)

*I register for the

Congress as:

*In case you register

as resident, nurse or student written

evidence of status must be provided by an employer’s statement or copy

of certificate. (to be sent as an attachment to the Congress

Secretariat: [email protected])

Number of accompanying persons:

I register for the Gala Dinner:

ESC membership:

I order a bagged lunch**:

** Note: Free lunches

will be provided to delegates attending the ‘Meet the Expert’ sessions

or ‘Sponsored Symposium”.

*I have to pay a total amount of

euro. (please make your own calculation: all fees are mentioned on the

page registration>>)

*I will participate in

the Welcome reception in the EICC’s Strathblane Hall (Wednesday, 23

June, 2004, 19:30 – 21:00) Free of charge

*I 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 please print out the pdf registration 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:

Note: after submitting

this registration form you receive a confirmation of the registration with

payment details to print out for your administration!