SWISS ICU NETWORK Fellows Symposium Registration Form 2015

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SWISS ICU NETWORK
Fellows Symposium
Registration Form 2015
To get registration it is mandatory to fill in all fields and to follow the
registration process given below point by point. Be adwised that registered
fellows are expected to attend the entire symposium from the first to the last
lecture. Non-compliance is regarded as severe violation of the symposium’s
rules: Better step aside and leave room for other fellows.
First Name:
Last Name:
Sex (male/female):
Year of board examination in intensive care (Switzerland):
(either give the year of the planned or the passed/missed examination)
Street address (home):
ZIPcode (home):
City/Town (home):
Active (daily retrieval) Email address :
Active Cell phone / Natel number :
I agree to share the hotel room with another person (y or n):
I will share my room with (give a name or „anybody“):
Registration Process:
1. Complete this form
2. Send this form as word document by Email to [email protected]
3. Within a few days you will receive either a registration number or a waiting list
number by Email to your Email address given above
4. Only in case you got a Registration number, you must activate your
registration within 2 weeks by paying the amount of 400.00 CHF to the
Swiss ICU Network bank account: SwissICU Network, UBS AG, IBAN:
CH030023323316482340T, BIC: UBSWCHZH80A (bank transfer only;
reference: registration number /last name)
5. You will get an Email as soon as your registration is activated
6. If you got a waiting list number you still have the chance to get a registration in
case a registered fellow has to cancel
If you have question: Send an Email
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