Download Registration Form_Retina Congress

REGISTRATION FORM
Trends in Surgical & Medical Retina
Barcelona, Spain, June 3rd and 4th 2011
Please, send a copy of the bank transfer receipt together with the registration form to:
[email protected] or the fax number (+34) 93 417 13 01
1. PERSONAL INFORMATION:
Last name
First name
Address
City
Postcode
Country
NIF/NIE/Passport
Institution
Department
Telephone
Fax
E-mail
2. INVOICING DETAILS (in case they differ from the participant´s details)
Company name
Address
City
Postcode
Country
VAT number
Telephone
Fax
E-mail
3. CONGRESS REGISTRATION
Registration fee
Registration before
April 1st
Registration after
April 1st
Participant
300 €
350 €
Instituto de Microcirugia Ocular de Barcelona (IMO) – Josep Mª Lladó, 3 (08035) Barcelona
Tel. (+34) 93 253 15 00 – Fax. (+34) 93 417 13 01 – [email protected] / www.imo.es
REGISTRATION FORM
Trends in Surgical & Medical Retina
Barcelona, Spain, June 3rd and 4th 2011
4. PAYMENT
Bank Transfer
Account name:
Bank:
IBAN Code:
Swift Code:
Trends in Surgical & Medical Retina
BBVA – Barcelona - Spain
ES74 0182-4370-81-0201515527
BBVAESMMXXX
Check List
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No charges to the recipient
The name of the participant appears on the bank transfer
Copy of the bank transfer must be enclosed with the form
DECLARATION
Your signature is mandatory in order to process your registration
Personal data provided will be included in a file under the responsibility of Institut de Microcirurgia Ocular de
Barcelona (IMO), in order to inform you of any activities, services and publications done by IMO. The processing of
personal data is for confidential use only and it will not be disclosed to third parties. You may exercise your rights of
access, rectification, cancellation and opposition by writing to the File Manager at the address Josep Mª Lladó, 3
(08035) Barcelona.
Date ………………………………………………………..
Signature ………………………………………………………………….
Instituto de Microcirugia Ocular de Barcelona (IMO) – Josep Mª Lladó, 3 (08035) Barcelona
Tel. (+34) 93 253 15 00 – Fax. (+34) 93 417 13 01 – [email protected] / www.imo.es