ESGE 2012 -Workshop on Advanced Endoscopy with Live Demonstrations
March 16-17, 2012 - Vienna General Hospital / Medical University (AKH)
 
REGISTRATION
 
Gender(*):
female male
Last Name(*):
Title / First Name(*):
Profession(*):
doctor
doctor in training
nurse
other:  
Institution:
Department:
Address(*):
Zip Code(*) / City(*) / Country(*):
Phone:
(Country Code / City Code / No.)
Fax:
(Country Code / City Code / No.)
E-mail(*):
Dieses Feld MUSS LEER bleiben!

(*) obligatory entry

Only applicable and obligatory entries for AUSTRIAN doctors:
 
ÖAK Nr.:
Date of Birth (dd/mm/yyyy):

Workshop Venue:
Vienna General Hospital (AKH) / Medical University
Hörsaalzentrum, Level 7
Währinger Gürtel 18–20, 1090 Vienna, Austria

I herewith register for the ESGE-Workshop, March 16 – 17, 2012 and will pay the related fees by bank transfer. Please note that your registration is binding with your submission.

Early Registration Fee - until February 24:
Physician (regular fee) € 350.-
ESGE Member € 280.-
ÖGGH Member € 280.-
Doctor in Training
        (confirmation/certificate must be provided)		 € 250.-
Nurse (regular fee) € 150.-
IVEPA member € 120.-
ESGENA member € 120.-

Registration Fee – after February 24:
Physician (regular fee) € 380.-
ESGE Member € 310.-
ÖGGH Member € 310.-
Doctor in Training
        (confirmation/certificate must be provided)		 € 280.-
Nurse (regular fee) € 180.-
IVEPA member € 140.-
ESGENA member € 140.-


Evening Reception on Friday, March 16, 2012
Please note: registration is mandatory, as seats are limited.

I will attend: yes no

1 Accompanying Person ticket à € 30.-


Comments:




Please note that your registration is binding with your submission.
After submission of this form you will receive an automatic e-mail confirming your registration.

We are at your disposal for any questions.

With best regards

Sandra Semlitsch, Andrea Etz
AZmed.info
phone: (+43/1) 531 16-70
e-mail: 

ÄRZTEZENTRALE MED.INFO
Helferstorferstraße 4, P.O. Box 155
A-1014 Wien / Vienna, Austria
Tel.: (+43/1) 531 16-70
Fax: (+43/1) 531 16-61
e-mail: