ISPE 2012
Investigational Products
Please return to: ISPE Registration Services
Avenue de Tervueren, 300 • B-1150 Brussels, Belgium
Tel: + 32 2 743 44 22 • Fax: + 32 2 743 15 84
E-mail: europeregistrations@ispe.org
Registration form
SAVE TIME – REGISTER ONLINE: www.ISPE.org/2012ipeuconference
I. Delegate Information
Prefix:____________________ First Name:__________________________________ Last Name:_________________________________________________
Job Title:__________________________________________________________ Company:_______________________________________________________
Address:_________________________________________________________________________________________________________________________
City:__________________________________________________ Postal Code:__________________ Country:______________________________________
Telephone:_________________________________________________ Fax:_ ____________________________
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
Company VAT
number (mandatory):_
________________________________________
II. Conference Registration
Prices below do not include VAT – 19% German 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.
q Tick here if you are a first time attendee
Registration Fees
(discounts cannot be combined)
Investigational Products
Wednesday 24 October – Thursday 25 October, 2012
ON OR BEFORE
AFTER
16 September 2012
16 September 2012
q ISPE Members
€1.395
€1.595
q ISPE New Members
€1.605
€1.805
q Non ISPE Members
€1.685
€1.895
€700
€700
q ISPE Board & Committees
III. Method of Payment
(19% German VAT should be included in the total payment, excluding €210 membership fee on New Member registrations)
Conference Fees €_________________________________________
19% VAT € _______________________________________________
Total Due:_€______________________________________________
q Credit Card q Amex
q Visa
q Mastercard­
Cardholder’s Name:_______________________________________________
Credit Card Number: |—|—|—|—| |—|—|—|—| |—|—|—|—| |—|—|—|—|
Expiry Date: |—|—| / |—|—|
Signature:
IV. Special Needs (dietary or other):______________________________________________________________________________________________
V. Dinner Tour Berlin – Wednesday 24 October
Come join your IP colleagues at a ‘Taste and Discover Berlin’ event on Wednesday 24 October.
The Berlin dinner tour is free to all IP Seminar delegates. Will you attend the FREE IP NETWORK DINNER? q Yes q No
VI. Hotel Information
Mövenpick Hotel Berlin
Schöneberger Strasse 3
D-10963 Berlin, Germany
Tel: +49 30 23 00 60 • Fax: +49 30 23 00 61 99
Room rates:
Single room: €149 (Breakfast included)
Double room: €169 (Breakfast included)
(Rates include 6% VAT, service charge and buffet breakfast _
and include city taxes of €6.40/room/night)
VII. Signature
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 10 September 2012 and the official booking form must be used.
You can make your reservation online through:
https://gc.synxis.com/rez.aspx?Hotel=19862&Chain=7714&Dest=BER&locale=de-DE&arriv
e=22.10.2012&depart=24.10.2012&adult=1&child=0&group=MA-MCI-221012
By signing I agree with the ISPE Registration and Cancellation Policies (see www.ISPE.org/2012ipeuconference)
Date:_ ___________________________ Signature: