online registration 7th seminar

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REGISTRATION FORM

7TH SEMINAR OF THE EUROPEAN SOCIETY OF
CONTRACEPTION

Budapest, Hungary  12-13 September
2003


Identification part
(*obligatory fields)

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


Department:
*Street/Number:

*Zip code:

*City:

*Country: 
Tel:


Fax:
E-mail:

The above identification details might be
used 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 kind of mailings:

 

 
Not ESC-related activities               

Company related information

Registration
part (*obligatory fields)

*I am a member of the
European Society of Contraception (ESC):
Hungarian
participants
*I register for the Seminar as: 
**For students: written
evidence of status must be provided by an employer’s statement or copy
of certificate.
*I pay as follows:
Participants
from other countries
*I register for the Seminar as: 
*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 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 (1) : after submitting
this registration form you receive a confirmation of the registration with
payment details to print out for your administration!
Note (2) : You can
attend the workshops of your choice by simply stating your preferences
on arrival. However, there will be limited spaces in each workshop so
please book up on arrival!

 

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