Lectures on MR 2015
Pre-registration Form
Prof.
Dr.
Mr.
Mrs.
Ms. □ Personal ID
Female
Male
Date of Birth (dd/mm/yyyy)*
First Name*
Family Name*
Hospital*
Institution
Department
Street/no.*
Phone
Profession*
Postal Code*
Country*
E-mail*
radiologist
clinical scientist, physician □ basic scientist, physicist, biologist, chemist
□ MR technologist/radiographer □ company representative □ of other profession
* required
City*
Registration applies only to the RF simulation on MR systems course in Heidelberg/DE!
RF simulation for MR systems: Coil design and safety
February 10-13, 2015
Heidelberg/DE
Early registration fees for LMR Heidelberg/DE
(until 8 weeks prior to the course beginning – the date of your pre-registration will be considered!
Basic scientists, physicians, MR technologists/radiographers and others with a professional degree:
□ ESMRMB Member*
€ 490
□ Non-Member
€ 660
PhD students and physicians in training*:
□ ESMRMB Member*
€ 340
□ Non-Member
€ 435
Late registration fees for LMR Heidelberg/DE
(after 8 weeks prior to the course beginning)
Basic scientists, physicians, MR technologists/radiographers and others with a professional degree:
□ ESMRMB Member*
€ 610
□ Non-Member
€ 805
PhD students and physicians in training*:
□ ESMRMB Member*
€ 410
□ Non-Member
€ 530
*To attend the Lectures on MR 2015 course as a member, ESMRMB membership fee for the year 2015 must be settled. Please
find out more on the ESMRMB membership types here.
ESMRMB Office, Neutorgasse, 9, 1010 Vienna, Austria, Phone: +43 1 535 13 06, Fax: +43 1 535 70 41, office@esmrmb.org
Lectures on MR 2015
Pre-registration Form
Terms of cancellation
In case of written cancellation of the registration by the participant
> 4 weeks before the course date: the registration fee less 20% for administrative costs will be refunded.
< 4 weeks before the course date: no refund will be granted.
If less than 20 participants register, ESMRMB reserves the right to cancel a course at the latest 4 weeks prior to its beginning.
Please keep this in mind for your travel arrangements. Please do not make any non-refundable travel arrangements! Please be
aware that the ESMRMB does not cover or refund for travel and hotel expenses in any case.
A maximum of 50 places are available! Early registration is therefore recommended.
Please read and accept the Terms and Conditions to continue your registration:
I herewith accept the terms and conditions of ESMRMB and I agree that my personal data,
consisting of my full name, profession, address (institution, hospital, department, home
address) and email address may be disclosed to ESMRMB sponsors, as listed on the website:
(http://www.esmrmb.org/cms/website.php?id=/en/society/industry_relations.htm).
I acknowledge that this personal data may be used to provide me with promotional material or
information relating to the field of radiology, as well as information on scientific events.
I also agree that the ESMRMB is entitled to send emails to me, containing promotional
information, on behalf of sponsors.
A list of ESMRMB sponsors is available on the following website:
(http://www.esmrmb.org/cms/website.php?id=/en/society/industry_relations.htm).
I reserve the right to revoke my consent to the disclosure of my personal data to third
parties at any time by sending an email to office@esmrmb.org
Payment
Bank transfer:
Account number 280-140-86-202 (ESMRMB) at "Die Erste Bank" Vienna (bank code 20111),
IBAN: AT072011128014086202, BIC: GIBAATWW. Please do not forget to state your full name and “Lectures on
MR, Heidelberg Registration". Please note that you are responsible for any bank charges that may apply.
Credit Card:
Eurocard/Mastercard
Visa
Name of Cardholder*
Credit Card Number*
Expiry Date*
Date*
Signature Cardholder*
Please return the filled in form either by e-mail, fax or postal mail to the ESMRMB Office.
Please be aware that your pre-registration is binding.
As soon as the registration is online, the respective registration fee according to your membership status will be
charged from your credit card by the ESMRMB Office.
Bank transfers have to be settled within 7 days after registration becomes available online, otherwise registration will
be cancelled.
ESMRMB Office, Neutorgasse, 9, 1010 Vienna, Austria, Phone: +43 1 535 13 06, Fax: +43 1 535 70 41, office@esmrmb.org