ISPE 2012
Conference SERIES
Please return to: ISPE Registration Services
Avenue de Tervueren, 300 • B-1150 Brussels, Belgium
Registration form
Tel: + 32 2 743 44 22 Fax: + 32 2 743 1584
E-mail: europeregistrations@ispe.org
SAVE TIME – REGISTER ONLINE: www.ISPE.org/2012QbDEUConference
I. Delegate Information
Prefix:___________ First Name:_____________________________ Last Name:__________________________________________
Job Title:________________________________________________ Company:____________________________________________
Address:____________________________________________________________________________________________________
City:_________________________________________ Postal Code:_____________ Country:_ ______________________________
Telephone:___________________________________ Fax:_ ________________________________
Company VAT
number (mandatory):_
Mobile:______________________________________ Email:________________________________
______________________
q I wish to keep my data confidential (only for use by ISPE and its local Affiliates and Chapters) q I do not wish for my details to be printed in ISPE’s Membership Directory or on Conference Attendance Listings
II. Conference Registration
Prices below do not include VAT – 21% Belgian VAT is applicable on registration fees only.
Are you an ISPE Member? q Yes , membership number: __________________ q No
If you wish to become a Member of ISPE and benefit from lower registration fees, please select New Member registration
fees. €210 (VAT exempt) for your one-year membership is included in the New Member fees indicated below. If you
do not wish to become a Member of ISPE, please select the Nonmember fees.
Registration Fees
(discounts cannot be combined)
QbD for Generics
Building a Successful Business Case Through
q EGA Members
q ISPE Members
q ISPE New Members
q Non EGA Members
q Non ISPE Members
q Academic - NGO - Government
ON OR BEFORE
1 June 2012
After
1 June 2012
€1.300
€1.500
€1.510
€1.710
€ 1.550
€ 1.750
€500
€500
III. Method of Payment
(21% Belgian VAT should be included in the total payment, excluding €210 membership fee on New Member registrations)
Conference Fees €________________
21% VAT € __________________
Total Due: €_ _______________
q Credit Card q Amex q Visa q Mastercard­ Credit Card Number: |—|—|—|—| |—|—|—|—| |—|—|—|—| |—|—|—|—|
Expiry Date: |—|—| / |—|—|
Cardholder’s Name:_______________________________________________ Signature:
IV. Special Needs (dietary or other):_________________________________________________________________
V. Hotel Information
Thon Hotel Brussels City Centre
Avenue du Boulevard 17
B-1210 Brussels, Belgium
Main Phone: +32.2.700.78.78
Reservations: +32.2.205.15.25
www.thonhotels.be/brusselscitycentre
Room rates:
Single room: 155€ (Breakfast included)
Double room: 175€ (Breakfast included)
(Rates include 6% VAT, service charge and buffet breakfast
and exclude city taxes of 6.40€/room/night)
ISPE has secured a number of bedrooms at a fixed group rate for your
convenience. All accommodation bookings must be made directly with the
hotel and are subject to availability.
To benefit from the ISPE group rate, reservations must be received before
15 May 2012 and the official booking form must be used.
The Booking Form is available online at www.ISPE.org/2012QbDEUConference The completed form must be returned directly to the Thon Hotel Brussels City Centre
by email to reservations@thonhotels.be or by fax
to +32 2.205.15.25
VI. Signature
By signing I agree with the ISPE Registration and Cancellation Policies (see www.ISPE.org/2012QbDEUConference)
Date:____________________________________ Signature: