Registration form 2016

For registration please fill out the form below.

mr.mrs.

Surname (required)

First name (required)

Profession (required)

Institute (required)

Member EAFPS yesno
Member ERS yesno

Private Postal address

Street (required)

Zipcode (required)

City (required)

Country (required)

Tel. (required)

Fax

Email (required)

Tuition fee
Please choose which course you will attend and if you are specialist or resident. Limited number of participants for the complete course with dissection.*

Dinner
I will attend the course dinner with persons and add €75,-per person to the tuition fee.


10% reduction of the fee for complete course for EAFPS and/or ERS members (not for dinner).

Payment
By direct credit transfer, in Euro ‘in full’ to ensure no commission fees or bank charges are deducted. The payment should be clearly identified with your name and the name of this course. Cheques and credit cards are not accepted. Please mention also IBANnr and BICnr.

*Payment for the complete course: only after confirmation of participation.

ABN/AMRO Amsterdam St. Aero
IBAN NL52ABNA0451037596
BIC: ABNANL2A

Registration will be closed September 15th, 2016.
Cancellation costs 50% before September 15th, and 100% after September 15th, 2016.