CONFERENCE REGISTRATION FORM
 
PERSONAL DATA
 
Gender(*):
female male
Last Name(*):
Title / First Name(*):
Profession(*):
MD
MD in training
PhD
 Clinical research
 Laboratory
 Basic science
MD, PhD
 Clinical research
 Laboratory
 Basic science
PhD Student
MD Student
Other: 
Field of research:
Institution:
Department:
Address(*):
Zip Code(*) / City(*) / Country(*):
Phone:
(Country Code / City Code / No.)
Fax:
(Country Code / City Code / No.)
E-mail(*):
Dieses Feld MUSS LEER bleiben!

(*) obligatory entry

Only applicable and obligatory entries for AUSTRIAN doctors:
http://abfrage.aerztekammer.at/index.jsf
 
ÖÄK-Arztnummer:
Date of Birth (dd/mm/yyyy):


I herewith register for the ITPD 2017 and will pay the related fees by bank transfer and credit card.
Please note that your registration is binding with your submission.

1) REGISTRATION FEES (in EURO) Bank Transfer Credit Card
Regular Fee - EARLY € 400,- € 410,- if registered and paid UNTIL June 15, 2017
Regular Fee - REGULAR € 450,- € 460,- if registered and paid AFTER June 15, 2017
MD in training € 350,- € 360,- please submit proof of training status together with your registration
Student € 250,- € 260,- please submit proof of student status together with your registration


2) Symposium DINNER - September 25, 2017 € 40,-
I will attend: yes no

3) Accompanying Person € 110,-
includes Reception, Symposium Dinner, Coffee Breaks & Access to Exhibition
Please indicate first and last name of the accompanying person here:
Last Name(*):
Title / First Name(*):

Comments:


Please note that your registration is binding with your submission.
After submission on this form you will receive an automatic e-mail confirming your registration / bank details for payment.



We are at your disposal for any questions.

With best regards

Jasmin Schneckenburger, Nina Strasser
AZmed.info
phone: (+43/1) 531 16-76 or -73
e-mail: 


ÄRZTEZENTRALE MED.INFO
Helferstorferstraße 4, P.O. Box 155
A-1014 Wien / Vienna, Austria
Tel.: (+43/1) 531 16-70
Fax: (+43/1) 531 16-61
e-mail: