Registration Form
Personal Information
*
Name
Surname
Date and place of birth
*
Date of birth
Place of brith
Fiscal Code
*
If not applicable, please digit 000
Affiliation
*
Entity, Hospital, University
Contractual Form
*
Please Select
Employee
Freelance
Affiliated with SSN
Affiliated with Other
Disoccupied
Student/Resident
Field
*
Please Select
Pathology
Audiology and Foniatrics
General Surgery
Maxillo-Facial Surgery
Plastic and Reconstructive Surgery
Nurses
Otolaryngology
Oncology
Radiodiagnostics
Radiotherapy
Contact Information
*
E-mail address
Phone
Special Needs
Please indicate allergies, intolerances, special dietary needs or any other needs
Registration Fees
*
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( X )
5° EHNS Workshop - Senior fee
€350.00
€
350.00
5° EHNS Workshop - Resident fee
€250.00
€
250.00
5° EHNS Workshop + 10° IHNS National Meeting - Senior fee
€500.00
€
500.00
5° EHNS Workshop + 10° IHNS National Meeting - Resident fee
€300.00
€
300.00
Gala Dinner
€70.00
€
70.00
Quantity
1
2
3
4
5
6
7
8
9
10
Select the payment method:
*
Bank transfer (the secretariat will send the details via e-mail)
Online credit card (the secretariat will send a personal link via e-mail)
Invoicing information
*
Header of the invoice
Fiscal address: street, town, postal code
Fiscal code
VAT number (if applicable)
Any notes
Send
Should be Empty: