REGISTRATION FORM PETROV RESEARCH INSTITUTE OF

 SEPTEMBER 16th – 18th, 2015 PETROV RESEARCH INSTITUTE OF ONCOLOGY SAINT PETERSBURG, RUSSIA REGISTRATION FORM PETROV RESEARCH INSTITUTE OF ONCOLOGY 68 Leningradskaya Str., Pesochny, Saint Petersburg, Russian Federation, 197758 Tel.: +7 812 596 86 05, fax: +7 812 596 89 4 7, e-­‐mail: [email protected] Registrant’s Details First Name: Second Name ( if any): Degree ( MD, PhD, MS etc): Family Name: Title (Prof, Assoc. Prof, etc): Afilliation ( Working p lace): Department/Institution: Address for correspondence: City: ZIP code (if any): Telephone number (most convenient): Country: Fax number ( if any): E-­‐mail address: REGISTRATION FEES: 1.
Including participation in the “hands-­‐on” sessions (number of participants is limited to 50): • EARLY REGISTRATION UNTIL AUGUST 1, 2015 7,000 RUR • LATE REGISTRATION FROM AUGUST 1, 2015 AND ON SITE 10,000 RUR 2.
Not including participation in the “ hands-­‐on” sessions: • EARLY REGISTRATION UNTIL AUGUST 1, 2015 3,000 RUR LATE • REGISTRATION FROM AUGUST 1, 2015 AND ON SITE 5,000 RUR Registration fee includes: • Active participation in all discussions and “hands-­‐on” session – f or Fee Type 1, and i n all discussions only – for Fee Type 2 • Course Materials • Coffee during the breaks • Lunch during lunch break • Certificate of Attendance CANCELLATION P OLICY FOR REGISTRATION FEES: For cancellations made up to August 1st, 2015 -­‐ 100% r efund will be granted. For cancellations made after August 1st, 2015 -­‐ no r efund will b e available. PAYMENT: I have transferred the total amount of ……………………. Rubles to the bank account of MEDI EXPO by bank t ransfer/ from my credit card to the bank a ccount of MEDI EXPO (select as appropriate) as a full payment for my registration to the IBUS COURSE 2015. I hereby attach the copy of the bank receipt. Note: • Bank Expenses should b e covered by yourself • The bank receipt must be forwarded to Medi Expo along with this f orm, by e-­‐mail or fax for your registration to b e confirmed I hereby confirm that I have read and agree with all terms, conditions and cancellation policy f or my r egistration in the IBUS COURSE 2015. Date: ____/____/____ Signature: ________________________ 310315