online registration 8th ESC congressBy contraception / June 7, 2021 REGISTRATION FORM 8TH 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: *select your title*Prof.Dr.Dr.other *Title for correspondence: *select your title*MrsMsMr 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: *please select*MrsMsMr 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): please selectyesnot yet All amounts are payable in Euro (registration fees: see page registration) *I register for the Congress as: please selectESC member 600 euronon ESC-member and pay 650 euro for registrationresident, nurse, student*and pay 400 euro for registration *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: please select1234 I register for the Gala Dinner: please select1 person2 persons3 persons4 persons ESC membership: please selectI register as new ESC member (50 euro) I order a bagged lunch**: please selectNo, I don’t orderThursday, 24 JuneFriday, 25 JuneThursday and Friday ** 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 please selectyesno *I pay as follows: please select your method of paymentby credit card (euro/master/visacard)bankers draftbank transfer 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 select your type of cardEurocard/MastercardVisa card 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!