ICPP13 Registration Form .pdf


Nom original: ICPP13 Registration Form.pdf

Ce document au format PDF 1.4 a été généré par Adobe InDesign CS5 (7.0.4) / Adobe PDF Library 9.9, et a été envoyé sur fichier-pdf.fr le 12/08/2016 à 17:38, depuis l'adresse IP 2.32.x.x. La présente page de téléchargement du fichier a été vue 382 fois.
Taille du document: 230 Ko (1 page).
Confidentialité: fichier public


Aperçu du document


April 21–23, 2017 (Nusa Dua, BALI)

INDIVIDUAL REGISTRATION
& HOTEL BOOKING FORM
REGISTRATION PROCEDURE:
• This form is for ONE registration only. For additional registrations, please photocopy this form or download it from our website www.icpp-thecourse.org
• Please type or print in block letters the following information & send this form to:
MEDIAXA/ICPP Secretariat: 18 rue Masséna • 06000 Nice • France • Tel +33 (0) 497 038 597 • Fax +33 (0) 497 038 598 • Email: cipp@cipp-meeting.org

PERSONAL DATA:



Dr

Mr

Mrs

Ms

Last Name ................................................................................ First Name ................................................................................... Specialty .......................................................................
Institute ...................................................................................... Department ...............................................................................................................................................................................
Address ....................................................................................................................................................................................................................................................................................................
City ................................................................................................ Postal Code ................................................................................ Country ..........................................................................
Phone .......................................................................... Fax .......................................................................... Email .........................................................................................................................
Accompanying Person (*) / Last Name ............................................................................................ First Name ............................................................................................................

REGISTRATION
FEES:



The registration fee entitles the participant to the followin



PACKAGE 1

800,00 €

• Conferences:

3 Days Course - Badge - Meeting bag containing ICPP educational material



3 Lunches + 4 Coffee breaks

• Catering:

PACKAGE
2 1200,00 €
• Conferences:

3 Days Course - Badge - Meeting bag containing ICPP educational material



• Accommodation:
3 Nights (April 20-21-22, 2017) in a single room (Including breakfast) at the Hotel Royal Riviera, Saint Jean Cap Ferrat
• Catering: 3 Lunches (April 21-22-23, 2017) + 3 Dinners (April 20-21-22) + 4 Coffee breaks



• Leisure:





Saturday April 22nd - Afternoon: Sightseeing Tour




• Accompanying Person(*):

(*) Registration for the accompanying person does not include attendance to the Course




Please complete & tick the appropriate box:



For your accommodation, you need

Single room





PAYMENT:


Credit Card:

- Evening: Dinner in a typical restaurant

400 € x ....... person(s)





Double room (only in case of accompanying person paying 600.00 €)

Additional night(s)

70 € x ...... night(s)

Additional bed

50 € x ...... night(s) (only in case of double)

Total amount to be paid: ................... €

Please charge my

Visa

Eurocard/Mastercard for the total amount due



Card # ........................... /........................... /........................... /...........................

Expiry date : .................... /...........



Cardholder’s name: ...............................................................................................

Cardholder’s signature: ....................................................................



CVV2 Code .............

Bank transfer: Please send this registration form along with a copy of the transfer order to the ICPP Secretariat
Paid by : ...................................................................................................

Last 3 digits at the back of your card

(fax# +33 497 038 598)



Date ................ /................ /................



TO: MEDIAXA/ICPP13 • BANK: BPCA - AGENCE DE LA BUFFA - 06000 NICE - FRANCE

Amount ....................



SWIFT CODE: CCBPFRPPNCE • BANK CODE: 15607 • BRANCH CODE: 00012 • IBAN #: FR76 1560 7000 1260 2212 3756 433

(Please do not forget to mention on the “transfer order”: Last Name / ICPP13)
Upon booking and payment, a receipt will be sent to you at the address mentioned on this form.

Cancellation & Refund Policy:
Cancellation of registration can be made up to December 31, 2017• Notification of cancellation must be sent in writing to the ICPP Secretariat.
The refund of registration, less a 25% administration fee, will be made after the Congress • There will be no refund if the cancellation is made after January 1, 2017




Aperçu du document ICPP13 Registration Form.pdf - page 1/1





Télécharger le fichier (PDF)


ICPP13 Registration Form.pdf (PDF, 230 Ko)

Télécharger
Formats alternatifs: ZIP



Documents similaires


icpp13 registration form
icpp13 registration form
k1izce0
tos
brochure ieee cdc 2019
contrat loc morzine chalet maia 16 23 mars 2013

Sur le même sujet..