PARTICIPANTS ON LINE REGISTRATION FORM

PERSONAL INFORMATION

Personal information are strictrly required for the CME report which we are obliged to provide to the Ministry of Health at the end of the Course.

TITLE   MSMRPROFDR

FAMILY NAME  

FIRST NAME  

DATE OF BIRTH  

Anno --194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011 / Mese --gennaiofebbraiomarzoaprilemaggiogiugnoluglioagostosettembreottobrenovembredicembre / Giorno --12345678910111213141516171819202122232425262728293031  

PLACE OF BIRTH   Please specify City and Country

ADDRESS OF RESIDENCE  

ZIP CODE  

CITY  

COUNTRY  

E-MAIL ADDRESS  

PHONE  

MOBILE  

PROFESSION/OCCUPATION  

DISCIPLINE

PLESE SPECIFY YOUR TYPE OF OCCUPATION  

EMPLOYEE IN A PRIVATE ORGANIZATION
EMPLOYEE IN A PUBLIC INSTITUTION
FREE PROFESSIONAL
OTHER

AFFILIATION/ORGANIZATION  

DO YOU NEED A VISA?   NOYES

IF YES, PLEASE UPLOAD THE COPY OF A VALID DOCUMENT OF IDENTITY OR PASSPORT

INVOICE DATA

DO YOU WANT TO INVOICE YOUR COMPANY OR ORGANIZATION?   NO (THE INVOICE WILL BE ADDRESSED DIRECTLY TO THE REGISTRANT)YES (FULL DATA ARE STRICTLY REQUIRED)

FULL NAME OF THE COMPANY/ORGANIZATION

COMPANY/ORGANIZATION ADDRESS

CITY/STATE

ZIP/POSTAL CODE

COUNTRY

COMPANY/ORGANIZATION FISCAL CODE OR VAT NUMBER (MANDATORY) IN ABSENCE OF THESE DATA THE INVOICE WILL BE ADDRESSED DIRECTLY TO THE REGISTRANT.

METHOD OF PAYMENT

Important notes: Payment must be made in Euros only. Registration must be accompained by the full payment.

BANK TRANSFER

UPLOAD THE REMITTANCE OF THE BANK (MANDATORY FOR PAYMENT MADE BY BANK TRANSFER)

CREDIT CARD

ACCOMMODATION DETAILS

Hotel bookings will be made directly by the Secretariat upon requests made and preferences expressed by this form. Hotel payment is the responsibility of registrants and shall be made directly to the hotel upon departure. Reservations will only be confirmed if credit card details are fully supplied as a guarantee of the hotel booking. Each participant will receive an individual confirmation letter, indicating the name and the address of the Hotel.

DO YOU NEED HOTEL ACCOMMODATION   YESNO

IF YES PLEASE SPECIFY:

HOTEL CATEGORY 3 STARS (€ 60 - € 110)4 STARS (€ 90 - € 140)

CHECK IN DATE GG/MM/YY

CHECK OUT DATE GG/MM/YY

ESTIMATED TIME OF ARRIVAL HH:MM

TYPE OF ROOM SINGLE ROOMDOUBLE ROOMTWIN ROOM (SEPARETA BEDS)

ACCOMANYING PERSON FULL NAME

Credit card details must be fully provided in order to proceed for the hotel booking and as a guarantee of the booking itself

CREDIT CARD   VISAMASTERCARDAMERICAN EXPRESS

CARDHOLDER'S NAME AND SIGNATURE ON THE CARD

CARD NUMBER

EXPIRATION DATE MM/YY