| |
*Input required |
| First Name* |
|
| Last Name* |
|
| Company/Institute* |
|
| Department |
|
| Specialty |
Surgeon
Radiotherapist
Medical Oncologist |
| Address* |
|
| Post Code* |
|
| City* |
|
| Country* |
|
| Telephone |
|
| Fax |
|
| E-Mail* |
|
| Only for Italian participants: |
Partita IVA or
codice fiscale |
|
| REGISTRATION FEE |
| Early rate |
payment received BEFORE
MARCH 26, 2010 |
550 EURO |
| Late rate |
payment received BETWEEN
MARCH 27 TO MAY 21, 2010 |
650 EURO |
| On site Registration AFTER MAY 21,
2010 |
850 EURO |
| |
| 12th MBCC + Breast Cancer Oncologic and
Rec. Surgery
Registration BEFORE MAY 21, 2010 |
1000 EURO |
| On site Rate AFTER MAY 21, 2010 |
1200 EURO |
| |
EUSOMA, EORTC, EUROPA DONNA
and SIS members and ex-allievi SIS
are entitled to 30% discount
only for
the 12th MBCC |
385.00 EURO |
| EUSOMA member |
EUROPA DONNA member |
| EORTC member |
SIS member |
ex allievi SIS |
| |
| Total to pay |
|
| The registration fee covers admission to the congress and
exhibition, a copy of the programme, coffee and
lunch throughout the congress and the official welcome cocktail. |
|
| ACCOMPANYING PERSON |
| Name |
|
| Accompanying persons will be admitted free of charge to the welcome cocktail. |
| ABSTRACT |
I have submitted an abstract (See instructions in the
programme) |
| I authorize the European Institute of Oncology to use my personal data for purposes relating to the
School’s activities. (required) |
| PAYMENT BY |
| CHEQUE |
|
PAYABLE TO CQ TRAVEL s.r.l.
via
Pagliano,3
20149 Milan Italy
(please send the cheque by post immediately after registration) |
| BANK TRANSFER |
|
to the order of CQ TRAVEL s.r.l. Banca Sella
Iban: IT98X0326801605052866945211
Swift code: SELBIT2B - Abi 03268 - Cab 01605 - Account n° 052866945211 |
| CREDIT CARDS |
|
Transaction with Sella.it Banca on Line
(please proceed and follow the instructions to enter the protected bank system) |
|
Please insert the following code
43838 |
|
This form enables one transaction every 2 hours |
|
|
| |
