Carta intestata GIO 2016 · REGISTRATIONFORM* To!be!returned!filled!within!MARCH!10 TH!...
Transcript of Carta intestata GIO 2016 · REGISTRATIONFORM* To!be!returned!filled!within!MARCH!10 TH!...
REGISTRATION FORM To be returned filled within MARCH 10TH
by fax to +39 050 7911239 or e-‐mail to [email protected]
REGISTRATION REGISTRATIONS WITHOUT FULL PAYMENT AND INVOICE DETAILS WILL NOT BE ACCEPTED
Last Name First Name .
M.D.□ Ph.D. □ Mr. □ Mrs. □ E-‐mail .
Organization Division . Title Address . Country City Zip code .
Mobile phone Telephone Vat Registration Nr. . REGISTRATION FEE (Current VAT 22% included) WITHIN January 15th 2016 AFTER January 15th 2016 ON SITE Delegate 305,00 366,00 366,00 Delegate UNDER 35 122,00 122,00 122,00
Identity Document (ID) is required for delegates UNDER 35. Registration fee includes: Congress Kit, Certificate of Attendance, Lunch and Coffee Break mentioned in program. Registration is required for all participants. Please send the Registration Form to: Evinco srl Fax +39 050 7911239 e-‐mail: [email protected] CANCELLATION & REFUND Requests for refund must be send within February 10th 2016 by e-‐mail to: [email protected]. All refunds will be sent after the Meeting. No refund will apply for cancellations received after February 10th 2016.
PAYMENT REGISTRATION FEE € ________ (PLEASE INDICATE AMOUNT DUE)
BANK TRANSFER DETAILS (IN EURO) Account Holder: Evinco srl -‐ Bank: CR Firenze Filiale 01706 Pisa -‐ IBAN: IT22D0616014000100000004346 -‐ bic/swift CRFIIT3F Payment Description: GIO2016 + Delegate’s name Copy of payment must be sent attached to registration form (registrations without payment will not be accepted) INVOICE will be issued for ALL registrations, therefore section below MUST be filled in Company Name / Partecipant name . Address . Social Security number (if available) . VAT Registration number .
INVITATION LETTER If required it will be sent by e-‐mail with your confirmation letter
□ required □ NOT required I confirm that I have read and accepted the cancellation and refund policy shown above. I hereby authorize the Organizing Secretariat: Evinco srl (Piazza A. D’Ancona, 3 Pisa) to the treatment of my personal data for all the aims related with the above mentioned meeting and according to the law 675 of 31.12.96 Date Full Name in block letters Signature .