REGISTRATION FORM
Participants should print and return
this completed registration form, together with payment,
before 15 September 2004 (after this
date, registration fees will be increased by 30%). To:
Last name:
|
_______________________________________________________________________________________ |
First name:
|
_______________________________________________________________________________________ |
Institution:
|
_______________________________________________________________________________________ |
Full Postal Address:
|
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________ |
Postcode:
|
_______________________________________________________________________________________ |
City:
|
_______________________________________________________________________________________ |
Country:
|
_______________________________________________________________________________________ |
Tel:
|
_______________________________________________________________________________________ |
Fax:
|
_______________________________________________________________________________________ |
E-mail:
|
_______________________________________________________________________________________ |
|
| Participant,
single room |
750.-CHF
(___) |
After
15 September 2004 |
975.-CHF
(___)
|
| Participant,
share double room |
550.-CHF
(___) |
After 15
September 2004 |
715.-CHF
(___)
|
| Accompanying
person |
300.-CHF
(___) |
After 15
September 2004 |
390.-CHF
(___)
|
| I agree
to share a room |
yes (___) |
no (___) |
|
I will share the room with: (last name: ______________________________
first name: ___________________________)
The total amount of _______________ CHF must be
transmitted by BANK TRANSFER to:
| Bank: |
UNION DE BANQUES SUISSES 1211 GENEVE |
| Account number: |
240/472 320.00 T |
| Name account holder: |
Université de Genève, Faculté
de médicine |
| Specifying: |
ETRS-NYON 2004 ME 6568 and Name of
Participant |
Payment should be made upon submission of the registration form.
Please, make sure that your payment already includes bank charges.
We do not accept payment by Credit Card.
50% registration fees will be refunded only if cancellation is received
in writing by 31 October 2004.
Special dietary requirements (please, specify): ___________________________________________________________
__________________________________________________________________________________________________
Smoker (please tick): yes (___) no (___)
|
