14th European Congress on Clinical Neurophysiology and 4th ?· 14th European Congress on Clinical Neurophysiology…

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<p>14th European Congress on Clinical Neurophysiology and4th International Conference on Transcranial Magnetic and Direct Current Stimulation</p> <p>Rome, 21-25 June 2011Centro Congressi Europa - Universit Cattolica del Sacro Cuore </p> <p>Please send this form directly to:OIC srl Professional Congress Organiser</p> <p>Viale Matteotti 7, 50121 Florence, Italy by 5 June 2011Phone +39 (055) 50351, fax +39 (055) 5035230, e-mail registrationECCN2011@oic.it</p> <p>or register online at www.oic.it/eccn2011 by 5 June 2011 at the latest! </p> <p>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 ___________________________________</p> <p>CONGRESS REGISTRATION The latest date for pre-registration is 5 June, 2011. After this date, please register on site.</p> <p> 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 </p> <p>14th European Congress on Clinical Neurophysiology and4th International Conference on Transcranial Magnetic and Direct Current Stimulation</p> <p>Rome, 21-25 June 2011Centro Congressi Europa - Universit Cattolica del Sacro Cuore </p> <p>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. </p> <p>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.</p> <p>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 95,00 105,00-115,00 125,00-150,00 170,00All hotel rooms are subject to availabilityType of room requested </p> <p> 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 __________________________</p> <p>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 </p> <p>No charges to the recipient. Copy of the bank transfer receipt must be enclosed with the form. The senders full name and address must be clearly stated in the transfer order as well as the payment purposes.</p> <p>Please charge the following credit card: VISA MASTERCARD AMERICAN EXPRESS </p> <p>Card no. _______________________________________________ Expiry date _________________________________ </p> <p>Security code (last 4 digits on the front of the card, AMERICAN EXPRESS only) _____________________________________</p> <p>Security code (last 3 digits on the back of the card, VISA and MASTERCARD only) _______________________________</p> <p>Cardholders name ________________________________________ ___________________________________________</p> <p>Overall amount (total) to be charged in EUR () ____________________________________________________________</p> <p>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 </p> <p> Date Signature </p> <p> ____________________________ __________________________________ </p> <p>Please head receipt of payment/invoice to: ________________________________________________________________________________________________________________________________________________________________(address, zip code, city, country)</p> <p>Fiscal / VAT code (MANDATORY)_____________________________________________________________________</p> <p>We accept to receive the invoice: by email as a PDF file - or - hard copy by post</p> <p>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. </p> <p> Date Signature </p> <p> ____________________________ __________________________________ </p>

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