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registration form - contraception-esc.com

registration form

10th Congress of the

European Society of Contraception

“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: [email protected])

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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