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European Society
of Contraception
|
Brussels, date
Dear sex Family_name,
Thank you for
your registration for the 8th Seminar of the European Society of Contraception
that will take place in Warsaw, Poland on 23-24 September 2005.
You
sent the following identification details:
| Title sex First_name Family_name |
| Institute Department |
| Address Zip_code City Country |
| Tel: |
Tel |
| Fax: |
Fax |
| E-mail: |
E_mail |
You do NOT wish to be included in the following kind of mailings:
| Not_ESC_related_activities |
| Company_related_information |
You are member_of_esc of the European Society of Contraception.
For your registration the total amount to be paid is due_payment
euro and you indicated to pay method_of_payment.
(– Account name: European Society of Contraception –
International Bank Account Number (IBAN): BE45 3101 2639 1389 – Bank name: ING Belgium
– SWIFT code: BBRUBEBB – Bank address: Marktplein 26, B-1740 Ternat, Belgium – Put in reference:
8th Seminar + your name)
If you indicated to pay by creditcard you provided us with
next data:
| Creditcard number |
cardnumber
|
| Exp.date |
exp_date |
| Name cardholder |
cardholder |
You are signature willing to
send your signature in writing to the ESC Central Office
if requested by your creditcard company. (only valid if
indicated that you pay by creditcard) |
If all mentioned data are correct you can print out a copy of this letter of
confirmation for your administration. If you want to change one or more items
you can go back to the registration form through clicking on the back arrow in
your browser.
With kind regards,
ESC Central Office
Opalfeneweg 3
B-1740 Ternat Belgium
E-mail: [email protected]
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