CONFERENCE REGISTRATION FORM
 
PERSONAL DATA
 
Gender(*):
female male
Last Name(*):
Title / First Name(*):
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 2019 and will pay the related fees by bank transfer or credit card.
Please note that your registration is binding with your submission.

1) REGISTRATION FEES (in EURO)
Regular Fee - EARLY € 410,- if registered and paid UNTIL June 1, 2019
Regular Fee - REGULAR € 460,- if registered and paid AFTER June 1, 2019
MD in training € 360,- please submit proof of training status together with your registration
Student € 260,- please submit proof of student status together with your registration


2) Symposium DINNER - September 9, 2019 € 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(*):


4) Payment Method
Bank Transfer
Credit Card (Mastercard, Visa, AMEX) After submission on this form you will be redirected to the payment site.

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.

The request for payment of the registration fee is effected in the name and on the account of the Austrian Society for Hygiene, Microbiology and Preventive Medicine (ZVR Nr./number in central register of associations: 720944593). The registration fee does not include VAT and therefore does not entitle to deduction of input tax.

(*) required



We are at your disposal for any questions.

With best regards

Lisa Thek, Jasmin Amon
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: 
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