Registration Form JHTA 2011

Please return this form dated and signed to:
AIM France - JHTA 2011
52, Rue Bichat - 75010 PARIS - France
Phone: +33 (0)1 40 78 38 00 - Fax: +33 (0)1 40 78 38 10
E-mail: [email protected]
Web: www.sfhta.org
REGISTRATION FORM
To participate to the 31es Journées de l’Hypertension Artérielle - 5th International Meeting of the French Society of Hypertension,
participants are kindly requested to register in advance. Groups reservation for sponsor/travel agency (6 individuals at least) must
be completed on line www.sfhta.org. You can register on-line (www.sfhta.org) or download and print this form to be returned by
regular mail or fax to the Congress Secretariat dully filled in, dated and signed. The registration fees include access to all sessions on
December 15 and 16, 2011, to the exhibition, the coffee breaks & lunches and the documents of the congress.
PARTICIPANT
Mrs
DETAILS
Miss
Mr
Prof.
FAMILLY NAME
FIRST NAME
In capital letters
in capital letters
Dr
ADDRESS
ZIP CODE
CITY
PHONE
FAX
COUNTRY
E-MAIL
VAT NUMBER
< 30
< 30 / 39 < 40 / 49
Age
Are you member of the French Society of Hypertension ?
< 50 / 59
> 60
Yes
No
INSTITUTION
Teaching Hospital
Research Institute
General Hospital
Other, specify:
Liberal Practice
Industry
SPECIALITY
Cardiology
Nephrology
Pharmacology Diabetology
REGISTRATIONS
General Practice
Internal Medicine
HTA
Anaesthetics / Intensive care Other, specify :
FEE
Until
November 21, 2011
From
November 22, 2011
SFHTA Members (2011 contributions up to date)
(Certificate required)
110
€
150
€
SFHTA non members
180
€
230
€
Permanent researchers and postdocs
(Certificate required)
60 €
Registration fees
One day registration (Precise the day)
80 €
80 €
100 €
Thursday or Friday
Thursday or Friday
Resident, Master’s Degree, Research Master’s
Degree, Nurse, Technician (Certificate required)
Free
Free
Press (Certificate required)
Free
Free
To pay subscription to the SFHTA or for more information, please contact the secretary:
Rachida M’SSIEH - Phone: +33 (0)1 44 90 70 30 - [email protected]
Please report your name :
Please return this form dated and signed to:
AIM France- JHTA 2011
52, Rue Bichat - 75010 PARIS - France
Phone: +33 (0)1 40 78 38 00 - Fax: +33 (0)1 40 78 38 10
E-mail: [email protected]
Web: www.sfhta.org
TRANSPORTATION
REGISTRATION FORM
DISCOUNT
You can ask for a rabat voucher to benefit from the travel reduction on the SNCF (French domestic railways only)
Do you want to receive a rabat voucher?
Yes
No
Air France ID code to for the booking 12600AF / Valid for travel from 09/12/2011 to 21/12/2011
CANCELLATION
POLICY
Cancellation of registration must be notified to the Congress Secretariat in writing (by regular mail, or fax) according to the following
conditions:
Cancellation on / before November 14, 2011: refund of 50% of the registration fees.
After November 14, 2011: no refund.
MEANS
OF
PAYMENT
Please indicate which of the following means of payment you intend to use:
By bank transfer (*)
(*) Clearly state « JHTA 2011 » and name of the participant
Please enclose receipt of bank transfer and registration form dully filled in.
Payment must be made to AIM FRANCE - JHTA 2011
Account n°: 1202529R002 - Key: 65 - Bank code: 40978 - Counter code: 00071
IBAN: FR87 4097 8000 7112 0252 9R00 265 - BIC: BSPFFRPPXXX
Banque Palatine - 17-19, Place de Catalogne - 75014 PARIS - France
By credit card, specify:
Visa
Eurocard / Mastercard
I authorize AIM FRANCE to debit the sum of
Card Number:
Euros on my credit card.
Security Code (**):
Expiration Date:
Card holder name:
Card holder address:
Card holder phone number:
Date:
Signature of holder:
(**) Note the last 3 figures of the number representing on the frame signature of your card.
Date:
Signature of participant:
Stamp