Registration Form 11 Arab Orthodontic Congress

Registration Form
11th Arab Orthodontic Congress
12th Lebanese Orthodontic Congress
October 31rst - November 3rd, 2013
at the Mövenpick Resort - Beirut, LEBANON
Program and hotel information: www.leborthosoc.com
Name: _______________________________________________ First Name:__________________________________________
Preferred Mailing Address:____________________________________________________________________________________
City: _________________________________________________ Country: ____________________________________________
Telephone: (______)__________________ Fax: (______)____________________ Email: ________________________________
FEES
1- Registration Fees (All fees are listed in U.S. dollars, including lunches and coffee-breaks, except lunch on Sunday, November 3rd)
BEFORE AUG 15
AFTER
AUG 15
LOS, WFO and AOS Member
Pre-congress course, Thursday, October 31rst
Meeting, Friday, November 1rst - Saturday, November 2nd
Post-congress courses, Sunday, November 3rd
 $125
 $200
 $50
 $150
 $250
 $75
 $200
 $300
 $150
 $250
 $350
 $200
 $75
 $100
 $25
 $100
 $150
 $50
Non Member
Pre-congress course, Thursday, October 31rst
Meeting, Friday, November 1rst - Saturday, November 2nd
Post-congress courses, Sunday, November 3rd
Students
Pre-congress course, Thursday, October 31rst
Meeting, Friday, November 1rst - Saturday, November 2nd
Post-congress courses, Sunday, November 3rd
2- Gala Dinner, Friday, November 1
rst
: Number of guests ____Total number _____x $75 = $ ______________________
TOTAL ENCLOSED:
$ ______________________
Cancellations, Changes and Refunds: Fees for missed meals, late arrivals, and early departures will not be refunded.
MODE OF PAYMENT
1- By MasterCard  or Visa  please print, complete and send by fax to +9611647435.
Card Number:________________/__________________/_________________/__________________
Expiry date:________________________________Security Code:________________________________
Signature:_________________________________ Date:_____________________________________
2- By Bank transfer in US dollars to:
Lebanese Orthodontic Society, IBAN: LB36/0056/0004/1260/7461/0020/3003 - SWIFT: AUDBLBBX
Audi Bank, Ashrafieh Branch, Beirut, Lebanon.
For alternative mode of payment: Please contact Dr. Chafic Tabbara +9613898313 - Email: [email protected]