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Please print in block letters and send by fax with payment details to:
Epilepsy Forum Secretariat, Fax: 86-010-65250423,
| A / PARTICIPANT : (please mark ?) |
| ? Dr. ? Pr . ? Mr. ? Mrs. ? Ms. |
| Last Name: First Name: |
| Organisation: |
| Address: |
| Country: Postal code: |
| Phone: Fax: |
| E-mail: |
| B / ACCOMPANYING PERSON( S ): (please mark ?) |
| B1 |
? Mr. ? Mrs. ? Ms. |
| Last Name: First Name: |
| B2 |
? Mr. ? Mrs. ? Ms. |
| Last Name: First Name: |
| C / REGISTRATION FEES : (please mark ?) |
| Registration fees |
Before 20/09/2006 |
After 21/09/2006 |
| Participant |
200 USD |
250 USD |
| Accompanying person |
100 USD |
125 USD |
| D / ADDITIONAL INFO. |
| Special Requirements (dietary, etc.): |
| |
| E / PAYMENT (please mark ?) |
| Payment Method: Credit Card or on spot |
| Card Type: |
□ Visa □ Maste r □ American Express |
| Name of Cardholder: |
|
| Expiry Date: |
MM: ?????????? Year: |
| Signature: |
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* Deadline date for receipt of registration : 09/20/2006
*Terms and Conditions:
Each participant must complete a separate registration form.
The forum Organiser does not assume any responsibility for any accident, injury or damage involving persons and/or property for the duration of the conference. Participants are advised to take out their own personal insurance.
* Cancellation Policy:
For Cancellation on or before 09/30/04 – Cancellation Fee 10%
For Cancellation on or before 10/15/04 – Cancellation Fee 50%
I have read and understood the terms and conditions as outlined above. I agree to abide by these terms and conditions and will not hold the forum organisers, its members, officers, administrative employees, or administrative officers liable for any damage, loss, expenses or injury arising from my participation in the event.
Signature: ____________________ Place and date: ____________________
download:
The Second Beijing International Epilepsy Forum Beijing 26-28 OCT 2006 Registrationform |
