14th European Congress on Clinical Neurophysiology and

4th International Conference on Transcranial Magnetic and Direct Current StimulationRome, 21-25 June 2011

Centro Congressi Europa - Università Cattolica del Sacro Cuore

Please send this form directly to:OIC srl – Professional Congress Organiser

Viale Matteotti 7, 50121 Florence, Italy – by 5 June 2011Phone +39 (055) 50351, fax +39 (055) 5035230, e-mail registrationECCN2011@oic.it

or register online at www.oic.it/eccn2011 by 5 June 2011 at the latest!

MAIN PERSONAL INFORMATION Please complete this form for ONE participant in block letters. Prof. Dr. Dipl. Ing. Mr. Mrs. male female Last name ___________________________________ First name _____________________________________ Institution________________________________________________________________________________CONTACT INFORMATION Address __________________________________________________ Unit, suite, floor____________________Post code _______________ City _______________________________Country __________________________E-mail (mandatory) ________________________________________________________________________ Telephone ___________________________________________Telefax ______________________________Fiscal/VAT Code (Mandatory for Italian Participant) __________________________________________________ ACCOMPANYING PERSON(S) Accompanying persons are not entitled to participate in the congress sessions, but are welcome to take part in social events and tours, if pre-booked and paid.Last name _______________________________ First name ___________________________________

CONGRESS REGISTRATION The latest date for pre-registration is 5 June, 2011. After this date, please register on site.

EARLY LATE REGISTRATION ON-SITEFEES (VAT included) REGISTRATION From 15 March 2011 REGISTRATION By 14 March, 2011 to 5 June 2011 Participants ECCN and 4th TMS-rTMS (21-25 June 2011) € 590,00 € 650,00 € 690,00Participants ECCN Congress (21-24 June 2011) € 490,00 € 550,00 € 590,00Participants 4th TMS-rTMS (25 June 2011) € 230,00 € 250,00 € 270,00Young Neurologists <40 (21-25 June 2011)* € 270,00 € 310,00 € 360,00Students** € 270,00 € 310,00 € 360,00 Technicians*** € 270,00 € 310,00 € 360,00Each teaching course € 55,00

Please indicate the required teaching Course_____________________________________________________________Block of 2 teaching courses € 100,00

Please indicate the required teaching Course_____________________________________________________________Accompanying Person§ € 150,00Exhibitors € 420,00

Total € _________________ * Born after 1st January 1970. Please attach a copy of identity document. The Young Neurologist registration fee includes the possibility to choose one Teaching Course free of charge. ** The copy of the Student card is required within 14 days of registration otherwise the regular fee will be automatically applied***Proof of status is required.§ Accompanying Persons Fee Includes: Opening Ceremony, Welcome Reception, two half day tours of Rome. Accompanying Persons are not entitle to attend the Scientific Sessions

SOCIAL PROGRAMMEPlease note: due to space limitation also free of charge events must be reserved.Tickets will be assigned on a first-come first-served basis. EVENTS Price per person (VAT included) Nr. Of persons Total €Welcome Reception, Tuesday 21 June 2011 Included in the registration fee check if you plan to attend Gala Dinner, Thursday 23 June 2011 € 70,00 X Nr………….. €

Total € _________________

OPTIONAL EXCURSIONS The programme of tours is available at www.oic.it/eccn2011

TOURS Dates Price per Nr. of Total € person persons Borghese Gallery - (Half Day) Tuesday 21 June 2011 € 50,00 X Nr……. € Vatican Tour & Baroque Rome - (Full Day) Wednesday 22 June 2011 € 115,00 X Nr……. € Tivoli Tour - (Full Day) Thursday 23 June 2011 € 115,00 X Nr……. € Jewish Rome & Campo de’ Fiori - (Half Day) Friday 24 June 2011 € 45,00 X Nr……. €

Total € _________________

14th European Congress on Clinical Neurophysiology and

4th International Conference on Transcranial Magnetic and Direct Current StimulationRome, 21-25 June 2011

Centro Congressi Europa - Università Cattolica del Sacro Cuore

HOTEL RESERVATION Room reservations can only be processed once your first downpayment has been received. The congress secretariat will confirm the booking and hotel details, according your choice. Balance is required by 20 April 2011.

Average prices (EURO a, including breakfast and taxes, VAT included)Category Single Occupancy Double for Double Downpayment min/max single use Occupancy per room € 20,00 Occupancy min/max booking fee incl.

4 stars A - € 220,00-260,00 € 250,00-280,00 € 300,004 stars B € 90,00-155,00 € 110,00-180,00 € 140,00-220,00 € 240,003 stars € 95,00 € 105,00-115,00 € 125,00-150,00 € 170,00

All hotel rooms are subject to availabilityType of room requested

No. _______ double room(s) No. _______ single/double room(s) for single use Smoking room Non-smoking room Date of arrival ___________ June, 2010 Date of departure ___________ June, 2010 Length of stay _____________nights Arrival after 18.00 hrs yes no Other requests ________________________________________________________________________________________(e.g. allergies, disability, vegetarian etc.) SUMMARYI herewith enclose the following amounts: Registration Fee € __________________________Social programme € __________________________Optional excursions € __________________________Hotel Reservation (including € 20,00 booking fee) € __________________________ TOTAL TO BE PAID € __________________________

TERMS OF PAYMENT: Payment by bank transfer: Account name: OIC srl Bank: Cassa di Risparmio di Firenze, Ag. 1, Viale Matteotti 20r, 50132 Florence, Italy IBAN: IT39 S061 6002 8010 0001 0628 C00 SWIFT: CRFIIT3F

No charges to the recipient. Copy of the bank transfer receipt must be enclosed with the form. The sender’s full name and address must be clearly stated in the transfer order as well as the payment purposes.

Please charge the following credit card: VISA MASTERCARD AMERICAN EXPRESS

Card no. _______________________________________________ Expiry date _________________________________

Security code (last 4 digits on the front of the card, AMERICAN EXPRESS only) _____________________________________

Security code (last 3 digits on the back of the card, VISA and MASTERCARD only) _______________________________

Cardholder’s name ________________________________________ ___________________________________________

Overall amount (total) to be charged in EUR (€) ____________________________________________________________

I hereby authorise the use of my credit card for the purposes specified above and, in case of hotel reservation, to charge the remaining balance by 20 April, 2011

Date Signature

____________________________ __________________________________

Please head receipt of payment/invoice to: ________________________________________________________________________________________________________________________________________________________________(address, zip code, city, country)

Fiscal / VAT code (MANDATORY)_____________________________________________________________________

We accept to receive the invoice: by email as a PDF file - or - hard copy by post

ATTENTION: Registrations can be considered valid only after receipt of the payment. Forms without payment will not be processed.DECLARATION - Your signature is mandatory in order to process your registration! According to the art. 13 D. Lgs. 196/2003, OIC srl and OIC Way srl are authorised to use my personal data for purposes connected to Congress management. I also confirm that I have understood the cancellation, payment and refund policy for individual registration as well as the hotel reservation terms and conditions specified in the announcement.

Date Signature

____________________________ __________________________________