2nd Macedonian Congress of Pathology with International Participation
1-4 September 2016, Ohrid, Republic of Macedonia
REGISTRATION FORM
Please forward the completed form to:
NAMIKO
Ankarska no.29a
1000 Skopje, Macedonia
A Personal details
Please complete using block letters
Phone: +389 2 307 1265
Fax: +389 2 306 4647
E-mail: map-2ndCongress2016@namiko.com.mk
❑ Ms
Family name:
❑ Mrs
❑ Mr
❑ Dr
❑ Prof
❑ Dr
❑ Prof
First name:
Institution/ Department:
Mailing address:
❑ private address
❑ institute address
Street:
Postal code, City:
Country:
Phone:
Fax:
E-mail:
B Accompanying Person
❑ Ms
Family name:
❑ Mrs
❑ Mr
First name:
For registered accompanying persons a Sightseeing Tour to Ohrid is included.
C Registration Fees (EUR)
Registration and payment
received
Early
Late and on site
by May 31, 2016
after June 1, 2016
MAP Member*
❑
Non-Member
❑ 100 EUR
❑ 120 EUR
Resident**
❑
60 EUR
❑ 80 EUR
❑
25 EUR
❑ 30 EUR
❑
30 EUR
❑ 40 EUR
One day***
___________
Accompanying Person
0 EUR
❑
EUR
0 EUR
* In good standing (membership fee for 2016 paid).
Please note that the member fee can only be granted if you are a member of the Macedonian Association of Pathology at the
time of registration. If you are not a member yet, you need to apply for membership first, and once you have received your MAP
membership confirmation, you can register at the member fee.
** Residents must submit a formal declaration from the Head of Department or the responsible for the training programme to
the congress office (e-mail and fax see above).
*** For one day registration please specify the date of attendance
Subtotal C: ___________
2nd Macedonian Congress of Pathology with International Participation
1-4 September 2016, Ohrid, Republic of Macedonia
D Social Programme
Social Programme*
EUR
Concert at St. Sofia Church
❑
15 EUR
Congress Official Dinner
❑
25 EUR
*(for accompanying persons and one day participants)
E Tours
Tours
EUR
Bitola – The City of Consuls
❑
50 EUR
Ohrid – The City of Light
❑
30 EUR
Subtotal D&E: ___________
F Payment
Total amount to be paid: _______EUR
Hotel reservations can be made by separate Accommodation form (link)
❑ I have transferred the amount (free of any bank charges) of EUR
on (date)
to your
bank account
❑
❑
EUR Bank transfer:
NAMIKO
IBAN: MK 07 210 3000003881 56
SWIFT: TUTNMK22
NLB Tutunska Banka AD, Skopje, Macedonia
MKD Bank transfer:
210 047670980 165
NLB Tutunska Banka AD, Skopje, Macedonia
I use the following credit card:
❑ Visa
❑ American Express
❑ Mastercard / Eurocard
Name as indicated on the card:
Street:
Postal code, City:
Country:
Card number:
Security number (see the back of your credit card)
Date
Expiry date:
Signature