H.E.A.R. final meeting
Registration Form

 Bibione, March 4-7, 1999
Venice - Italy

Please note that the fields which are required to be filled before submitting the form, ARE INDICATED by a red asterisk. Thank you!

  Partecipant 
 Title
  Prof. Dr. Mr. Mrs. Ms.
 Last Name*  
 First Name*  
 Middle Name  
 Institution  
 E-mail*  
 Address*  
 City*
   ZIP*  
 Province/State
   Country*
 Phone*
  Fax 

 Accompanying Person 
 Last Name  First Name

 Registration Fees in USD(*) 
Participant (500.00$)*
Accompanying Person (300.00$ each) (*) Fee includes: accomodation, meals, transport from and to Venice Marco Polo Airport, social program for both participants and accompanying person and, for participants only, congress fee.
Total

  Payment* (please check one) 

Credit Card
Master Card
VISA
American Express

You NEED to FAX to the Savoy Beach Hotel fax number these Credit Card Info:
  • Credit Card type
  • Credit Card number
  • Credit card expiration date
Money Transfer To:
Banca di credito Cooperativo "San Biagio" di Cesarolo e Fossalta di Portogruaro
Corso del Sole, 104/a
Filiale di Bibione (VE) - ITALY

ABI Code: 8965 CAB Code: 36291 Account # : 6040
International Check   You NEED to mail the check to the Savoy Beach Hotel address

 Congress and accomodation will be at:
Savoy Beach Hotel
Corso Europa, 51
BIBIONE (Venezia) - ITALY
Voice: +39 (0431) 43-0144
Fax: +39 (0431) 43-9311
           
Please choose*:
Single Room
Double Room


If you do not want or you cannot submit this form, print it and then fax or mail it to:
Prof. Alessandro MARTINI
Istituto di Clinica ORL
Corso Giovecca 203
44100 Ferrara - ITALY
Voice: +39 (0532) 20-6138
Fax: +39 (0532) 23-6887
E-mail: mma@dns.unife.it


© 1998 H.E.A.R. - University of Ferrara - Author: Leopoldo Saggin
Info on this page: mma@dns.unife.it - Last Revision: December 17, 1998
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