DELEGATE DETAILS:

PLEASE USE CAPITAL LETTERS WHEN COMPLETING THIS FORM ( Required fields )*

PARTICIPANT

Title

Prof.

Dr.

Mr.

Mrs.

Ms.

Surname

*

Name

*

Address

*

City/State

*

Country

*

Post code

*

Phone

*

fax

E-Mail

*

mobile

Practice Specialty

*

FISCAL CODE (for italians only)

ACCOMPANYING PERSON

Name

Surname

Age

Invoice to:

Participant

Company

Company Name

Contact Person

Address

VAT CODE (where applicable)

Country

Post Code

Phone

Fax

E-Mail

mobile

Conference Costs:

Registration Fees

in euros, per person, tax included

Before September 7

After September 7

Tot

Registration

€ 390,00

€ 460,00

Nr

Gala Dinner

€ 120.00

auto total

TOTAL CONFERENCE COSTS

auto total

Accommodation Deadline for accomodation: 1st september 2008

WESTIN EXCELSIOR (VENICE LIDO) AAVIS MAIN CONGRESS_2-4 October FULL BOOKED

Arrival date (es. dd/mm/yyyy) * departure date (es. dd/mm/yyyy) *

x night

DD (Double room - double occupancy)

auto total

x night

DUS (Double room - single occupancy)

auto total

auto total

BIRI HOTEL (PADUA) PRE CONFERENCE WORKSHOPS_30 September-1 october) FULL BOOKED

Arrival date (es. dd/mm/yyyy) * departure date (es. dd/mm/yyyy) *

x night

DD (Double room - double occupancy)

auto total

x night

DUS (Double room - single occupancy)

auto total

auto total

TOTAL € ACCOMMODATION

€

ON BEHALF OF PERSON FOR WHOM THIS REQUEST IS MADE, I HAVE READ, UNDERSTOOD AND AGREED TO BE BOUND BY THE CONDITIONS SET OUT IN THIS FORM

FOR ALTERNATIVE ACCOMODATION PLEASE CONTACT DIRECTLY OUR SUGGESTED HOTELS.

(BANK TAX)

Total

€

Secure Payments Bankpass Accepted Credit Card For your security, the data concerning the purchase will be transmitted with the crypted protocol SSL (Secure Socket Layer) on 128 bit, and managed on the bank server.