REGISTRATION FORM
THE 19TH ANNUAL STŘEŠOVICE TRANSFUSION DAY
Name
*
Name
Last name
Titles
Email
*
example@example.com
Phone number
*
-
Area code
Number
Date of birth
*
-
Day
-
Month
Year
Country
*
Organisation
*
City of organisation
*
Profession details: What is your professional group?
Please Select
MLT
Nurse
Physician
Analyst
Medical scientist
Research scientist
Other
Registration fee
*
Regular registration fee - 900 CZK (38 EUR)
Invited guest - 0 CZK
Payment method
*
Myself – I am a private individual and self-payer – I do not need a tax invoice, a simple payment confirmation with my name is sufficient.
Organization – Hospital, pharmaceutical company, sponsor – please provide billing details.
Billing address
*
Name of organization
Street
City
Country
ZIP code
VAT ID
Please fill out the VAT ID of your organization
Total amount CZK
Do you want to pay by credit card?
Please Select
YES
NO
Amount to pay
prev
next
( X )
CZK
If you didn't select card payment, please wait for the invoice, which you’ll need to complete the payment. You should receive it within about 3 working days after registering.
Payment Methods
Debit or Credit Card
Choose from one of the PayPal options to
make your payment.
SEND
Should be Empty: