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r e g i s t r a t i o n
f o r m
Barcelona
• 2-3 December 2005
FIFTH EUROPEAN ANTIPHOSPHOLIPID FORUM
Family Name: . . . . . . . . . . . . . . . . . . . . . . . . . . .
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First Name: . . . . . . . . . . . . . . . . . . . . . . . . . . .
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ICN (Identi.cation Card Number): . . . . . . . . . . . . . . . . .
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Dept./Institution: . . . . . . . . . . . . . . . . . . . . . . . .
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Address: . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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City: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . Postal Code: . . . . . . . . . . . . . . . . . .
Country: . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Telephone: . . . . . . . . . . .
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E-mail: . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Registration Fees in Euros: (VAT not included)
• Members of the FORUM Yes
. No .
For FORUM members, name of the Forum Project involved:
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• Members of the FORUM: Free of charge
• Non Members: 100,00 € + 16%
VAT
(places are limited, so please book early to avoid disappointment)
Method of Payment for non Members of the Forum:
• Nominal cheque in Euros made payable to: “S&H
Medical Science Service”.
• Bank transfer in Euros to: “S&H Medical Science Service”
(Name of the Bank: BBVA – Account Number: 0182-0190-81-0201544396)
Please return this Registration Form by
Fax or postal mail to the
Technical Secretariat
S&H Medical Science Service
Espronceda, 27 – 1º A. 28003 Madrid
Telephone: +34 91 535 71 83:
Fax: +34 91 554 41 14
E-mail: congresos@shmedical.es
(please attach a copy of your bank transfer or cheque)
• The registration fee includes access to all scientic sessions,
lunches, coffee breaks and closure dinner.
The personal details included in this
document are of con.dential nature. In accordance with the Organic Law
15/19999 of 13 December, the holder
of this data will be able to exercise his or her right of access, recti.cation
and cancellation in written
application to sh@shmedical.es
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Created and updated by Department of Autoimmune Diseases, Hospital
Clínic, Barcelona, Catalonia, Spain |
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Web contents: EFAPL Info Desk. |
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Last updated: 03 September 2005 |
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