Registration Form
Personal Information
*
Name
Surname
Date and place of birth
*
Date of birth
Place of brith
Affiliation
*
Entity, Hospital, University
Contact Information
*
E-mail address
Phone
Special Needs
Please indicate allergies, intolerances, special dietary needs or any other needs
Registration Fee
*
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( X )
ENT
€
300.00
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 (if applicable)
VAT number (if applicable)
Any notes
Send
Should be Empty: