ON-LINE REGISTRATION 2013 INTERNATIONAL POST-GRADUATE CORSE ON RESPIRATORY AND CARDIOVASCULAR DISEASES

PERSONAL DATA

FAMILY NAME  

FIRST NAME  

E-MAIL  

PLACE AND DATE OF BIRTH   City and Country, Date

HOME ADDRESS   Address, Zip Code, City and Country

PHONE No.  

Anno --1999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026202720282029 / Mese --gennaiofebbraiomarzoaprilemaggiogiugnoluglioagostosettembreottobrenovembredicembre / Giorno --12345678910111213141516171819202122232425262728293031  

TRAVEL AND ACCOMODATION DETAILS

TRAVEL AND ACCOMODATION EXPENSES WILL BE PAID BY ORGANIZING SECRETARIAT

TRAVEL DETAILS   Do you want the Secretariat to book your travel tickets? PLEASE NOTE THAT SECRETARIAT WILL PROVIDE PREPAID BUSINESS CLASS TICKETS ONLY FOR INTERCONTINENTAL FLIGHTS YES, PLEASE BOOK MY TRAVEL AS FOLLOWS:NO, I WILL ASK FOR REIMBURSEMENT AT THE END OF THE MEETING

If YES, please provide for the following information: ARRIVAL FROM (CITY)

DEPARTURE DATE AND PREFERRED TIME

TO (CITY)

DEPARTURE DATE AND PREFERRED TIME

If NO, in order to guarantee pick up from and to airport/railway station, please provide for the following information: DEPARTURE FROM (CITY), DATE AND TIME

AIRPORT/RAILWAY STATION

FLIGHT OR TRAIN No.

FROM ITALY, DEPARTURE DATE AND TIME

AIRPORT/RAILWAY STATION

FLIGHT OR TRAIN No.

HOTEL ACCOMODATION ACCOMODATION WILL BE PROVIDED BY THE ORGANIZING SECRETARIAT AT SAN SERVOLO ISLAND (VENICE). PLEASE PROVIDE WITH THE NAME OF ACCOMPAYING PERSON, IF ANY.

ARRIVAL DATE (FOR HOTEL BOOKING)  

DEPARTURE DATE (FOR HOTEL BOOKING)  

NUMBER OF NIGHTS  

TYPE OF ROOM  

Single

Double

Twin (2 separate beds)

ACCOMPAYING PERSON Please note that accompanying people expenses cannot be covered by the congress organization

SOCIAL EVENTS DINNERS WILL BE ORGANIZED BY THE SECRETARIAT, PLEASE PROVIDE FOR YOUR KIND CONFIRMATION

Thursday 21st November

Friday 22nd November