CULT 2011
COMPLETE IN CAPITAL BLOCKS AND
CHECK APPROPRIATE FIELDS AND BOXES
Send by fax to +39 050 974148 or by e-mail to
[email protected]
Cardiac Interventions Under the Leaning Tower
Around percutaneous valve procedures
Pisa (Italy) January 27/28, 2011
REGISTRATION FORM
Thank you for your interest in the CULT 2011 Conference! If you have any questions, please contact Paola Benedetti at Ph. +39 050 9711721
Title
Prof.
Dr.
Mr.
First Name
Last Name
E-mail
Affilation
Ms.
Mrs.
Affilation Address
Postal code
Invoice Address
Telephone
City/Country
(Please include your company name and V.A.T. number or CODICE FISCALE)
Fax
(Including international code ex: +39 050 9711721)
Registration Fee (20% V.A.T. Included)
before October 30, 2010
after October 30, 2010
€ 240,00
€ 300,00
€ 190,00
€ 250,00
2 days conference
1 days conference
Please check one of the
following box
27 Jan. 28 Jan.
PAYMENT BY CREDIT CARD
MASTERCARD
Card Number
VISA
Exp. Date MM/YY
Card holder’s name
V-code
(the Verification Code is a three-digit number on the back of your credit card)
Amount E
Card holder’s signature
PAYMENT BY BANK TRANSFER - Please fax this form with a copy of payment to +39 050 974148
REGISTRATIONS WITHOUT COPY OF PAYMENT ISSUED BY BANK WILL BE NOT PROCESSED
Bank Name: Monte dei Paschi di Siena Agenzia n. 3 - Bank Address: Via Scornigiana Loc. Ospedaletto Pisa Italy
Bank Account number: 170924 - ABI CODE: 01030 - CAB CODE: 14004 Account Name: Meridiana Events & Education srl
IBAN CODE: IT 42 Z 01030 14004 000000170924 - BIC SWIFT CODE: PASCITM1PI3
Bank transfer must be detailed by:
REGISTRATION (in case of 1 day attendance, please specify the date) + NAME OF PARTICIPANT + CULT2011
Sender must pay for bank fees. In case bank fees are charged on the conference account, Meridiana will invoice the sender with the bank fees plus 20% handling fee + taxes.
INFORMATION
Pre-registration will be accepted until January 20, 2011. After this date only on site registration will be accepted.
REGISTRATION FEE INCLUDES: Access to the education sessions and conference kit. Lunch and coffee breaks are included only for the attendance on the 28th.
CANCELLATION POLICY: any cancellation must be sent in writing by letter, fax or email, not by phone. Cancellations received before November 15, 2010 are refundable less a cancellation fee of E 60,00 (including 20% vat) per person. No refunds
can be made after November 15, 2010 in any circumstances.
REFUNDS: all refunds will be issued by bank transfer within 60 days of the conference’s conclusion.
DISCLAIMER: Meridiana Events & Education will not accept liability for any losses and/or damages participants may suffer on account of alteration or cancellation for any reason including ill health. Participants are advised to arrange adequate travel and health insurance.
NAME SUBSTITUTIONS: can be made at any time for an administration fee of Eur 50,00 (including 20%) per person.
MANDATORY: by sending this registration form, I acknowledge that this form will be logged in a Competency Group maintained conference list. I allow the conference secretariat to send me updated information about the CULT 2011 Conference.
I will be allowed to contact the conference secretariat anytime in order to remove my form from the list.
Information Note pursuant to Art. 13 of the Italian Civil Code concerning personal information protection (under Legislative Decree #196 dated 30 June 2003, containing the Consolidating Act regulating the protection of persons
and other entities as to the processing of their personal information).
Your personal information and details made available for the purpose of registration to this event will be processed in compliance with the above-mentioned legal provisions and confidentiality obligations that inspire MERIDIANA EVENTS &
EDUCATION’s activity. Your personal information will be processed to proceed with Your registration and send You further information materials regarding our organization’s activities.
Date
Signature