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ASPIC İstanbul 2024
Registration Form
Name - Surname
*
Name
Surname
ID Number
*
We need for Sending QR Code to Access your badge at Registration Desk. You may write Passport ID
Email
*
Phone Number
*
-
Country Code
-
Code
Number
Institution / Company
*
Address
*
Address 1
Address 2
City/Province
State
Zip / Postal Code
Registration Type
Registration Type
*
Please Choose
Physician
Assistant
Fellows, Nurses, Technicians or Students
Industrial Representatives
Abstract Presenter
Member of PEDKAR Physician
Member of PEDKAR Fellows, Nurses, Technicians or Student
Please choose your registration type and unit below
Registration
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Early - Physician
€
500.00
Quantity
1
2
3
4
5
6
7
8
9
Item subtotal:
€
0.00
Early - Assistant & Nurse
€
400.00
Quantity
1
2
3
4
5
6
7
8
9
10
Item subtotal:
€
0.00
Early -Industrial Representatives
€
500.00
Quantity
1
2
3
4
5
6
7
8
9
10
Item subtotal:
€
0.00
Payment Details
Name
Surname
Credit Card Number
Security Code
Valid Number
Please Additional Type Name and Surnames
Signature
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