Send the registration form and a copy of payment to Fax n. 0039 06

registrAtion Fees
Send the registration form and a copy of payment to Fax n. 0039 06 3233304
or to [email protected]
registrAtion Form
name
Surname
Address
city
code
e-mail
Phone
Fiscal code
date of birth
mobile
/
/
inVoiCe inFormAtion
company
Address
city
e-mail
Phone
VAT number
State
Full Congress registrAtion Fee
(18-19-20 june)
qSurgeon and dentist
Before April 30 th
Courses Fee cloSed number
qmicro Surgical endocourse (Prof. Kim)
qSinus elevation course (Prof. Testori)
Before April 30 th
120,00+VAT 22%
120,00+VAT 22%
300,00+VAT 22%
390,00+VAT 22%
the registration fee entitles you to:
- participation in only one of the symposia provided daily (please select your choice)
- simultaneous translation where applicable
- conference kit and entrance to the exhibition
- coffee break
- certificate of attendance
symposium preFerenCe
qendo-operative Symposium
june 18th
june 19th
qPerio-implant Symposium
qortho-prostho Symposium
june 20th
Place of birth
After April 30th
After April 30th
150,00+VAT 22%
150,00+VAT 22%
qregenerative Symposium
qmultidisciplinary Program
qmultidisciplinary Program
CAtering
lunCH for 3 days q € 75,00 lunCH DAily q € 25,00 gAlA reCeption q € 35,00
code
State
mobile
pAyment
All payments must be made in euro. You can choose between two forms of payment, either credit card
payment or bank transfer. We strongly recommend the credit card payment as charges for bank transfers
may apply twice, once in the country of origin and a second time in the target country.
• CreDit CArD:
q Visa
q Mastercard
card Holder _____________________________________
number _______________________________exp. date___________ Security number_____
A bank fee of 5% will be applied on each payment.
• BAnk trAnsFer to tHe Congress BAnk ACCount:
medIcon ITAlIA conGreSSI Srl - banca Popolare di milano Ag. 260
iBAn: it 46 u 055 6 8403 2090 0000 0008 249
BiC (sWiFt-CoDe): Bpmiitm1260
bank address: Via cassia 901 – 00191 roma (rm) - Italy
qregistrAtion Fee............. qCourses............. qlunCH pACkAge..............
qgAlA reCeption € 35,00
ConFirmAtion
totAl to pAy
€ .......................
upon receipt of the registration and the corresponding payment, the congress office will send a confirmation to the participant which also serves as an invoice. Please show this confirmation of registration at
the congress counter when picking up your congress material.
CAnCellAtion
In the event that the attendance at the congress is cancelled 15 days before the event, the participant
will be entitled to a refund of 50% of the amount paid. no refund will be made if the registration is cancelled at a later date. Please notify the organizing Secretariat of your cancellation in writing. refunds will
be made within 60 days from the closing date of the congress
priVACy inFormAtion
Information ex Art. 13 of the civil code in matters of personal data (legislative decree 30 June 2003, n. 196 - consolidated the rules on the protection of persons and other
subjects regarding the processing of personal data) The common information and data provided by you for entry to this event will be processed in accordance with the above
provisions and obligations of confidentiality that inspire the activities of medicon Italia congressi srl. The data processing will be carried out to give way to his inscription,
sending of information by our company, administration and non-accounting. The approval of the treatment is optional, but in case of lack thereof medicon Italia congressi srl
will not be able to deliver all or some of the services covered by this registration. For a more vision please refer to the dl 196 / 2003e of the content of Articles. 13:07.
q i give my consent to the processing of my personal data.
q i do not give the consent to the processing of my personal data, except to this event to the treatments required statutory.
date
/
Signature
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