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Registration form

The Vth National Conference of Bronchology
Timisoara, 12 November 2009 - 14 November 2009

SC Convention & Event Professionals SRL

HDQ : 300654 Timisoara, Romania
Circumvalatiunii III bl7 scd ap18
Branch office : 300223 Timisoara, Romania
Bd Vasile Parvan 1-3

tel +40 356 108090, fax +40 356 108089, fax +40 256 244468
e-mail : office@eventprofessionals.ro, convention@eventprofessionals.ro

I apply for: The Vth National Conference of Bronchology
First Name: *
Initials: *
Last Name: *
Title: Mr. Mrs. Ms.
Prof. Dr.
WORKPLACE
Name: *
Department:
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Town: *
Poscode:
Country: *
Phone: *
Mobile: *
Fax:
E-mail: *
PERSONAL ADRESSE
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Poscode:
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Phone: *
Mobile: *
Fax:
E-mail: *
 
FEE REGISTRATION
Registration fees Early
registration fee
until : 15/10/2009
Regular
registration fee:
15/10/2009 – 01/11/2009
Late
registration fee
after: 01/11/2009
Doctors SRP members
Doctors non-SRP
Members Residents
Nurses SRP members
Nurses non-SRP members
Accompaniants
300 RON
400 RON
150 RON
100 RON
150 RON
100 RON
400 RON
500 RON
150 RON
150 RON
150 RON
150 RON
500 RON
600 RON
200 RON
200 RON
200 RON
200 RON
Method of payment: until 10.11.2009 via bank transfer:
SOCIETATEA ROMANA DE PNEUMOLOGIE
Bank account (RON) RO38BRDE410SV20979184100 BRD - SUCURSALA I.C. BRATIANU
(With mention “for the V th National Conference of Bronchology with international participation”)
from 15.10.2009 in cash at the registration desk (without hotel reservation )
Number of payment receipt:
Payment date: *
Please type the text shown in the image into the box below
   




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