Registration

Name *	Mr. Ms.
Title(s) and affiliation(s)
Office Practice or Institution Name *
Office or Institution Address *	Nr. *
Postal code */City *
Country *
Business Phone *
Fax
Home Address (if preferred)	Nr.
Postal code/City
Country
Home Phone
E-mail*
Yes I would like to attend the meeting on September 23 - 24 2010, in Lisbon I will stay from September 23 - 24, excluding stay in the hotel à € 475,- I will only attend the meeting on September 23 à € 250,- I will only attend the meeting on September 24 à € 250,- I am a registrar/trainee or medical student ** I will stay from September 23 - 24 à € 250,- (excluding hotel) (**) Student Fee: Applications must be accompanied by a letter from the applicant's Head of Department stating full time undergraduate student status. EPCCS Conference Accommodation Yes, I would like to book a room at the conference hotel (Corinthia) for the nights of: 21 September 22 September 23 September 24 September 25 September Rate € 175 per person, per night (including breakfast & taxes) No accommodation required
Payment details Please provide us with correct payment information. For Dutch delegates it is possible to pay via Automatisch Incasso. It is also possible to pay with your Mastercard or Visacard. Pay with Mastercard or Visacard (you will be contacted for your credit card details) Payment using Automatisch Incasso for Dutch delegates Please provide us with your bank account information: Account holder name / Account number
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