REGISTRATION FORM
PERSONAL DETAILS AND ADDRESS FOR CORRESPONDENCE
Title:
First Name:
Family Name:
Name for Badge:
BIG registration number:
(for Dutch Gaia
INSTITUTION/HOSPITAL:
Address1:
Address2:
City:
Postal Code:
Country
Telephone:
E-mail:
registration only)
Please mark your choices with “X”
preferably attach to Email: esctaic2010@vumc.nl
Alternatively: Fax: +31 204444385
A) CONGRESS
>15-06-2010
ESCTAIC member
€ 280 per person
Non member
€ 330 per person
Accepted free paper
€ 220 per person
One Day Registration
Wednesday
€
75 per person
One Day Registration
Thursday
€ 150 per person
One Day Registration
Friday
€ 150 per person
B) TUTORIAL
IHE
phys. Modelling
ESCTAIC member
€ 70 per person
€ 80 per person
Non member
€ 90 per person
€ 100 per person
C) WORKSHOPS
ADAM
ESCTAIC member
Non member
AIMS
€ 15 per person
€ 20 per person
OR
€ 20 per person
€ 25 per person
I will attend the general assembly and congress dinner Friday 8th
20:00 boarding at Stopera
(incl.in full registration € 35 for day registrants)
All Payments should be made in Euro to:
Stichting Onderwijs Research Fonds Anesthesiologie
Bank: ING, Amstelveenseweg 500, 1081 KL City: Amsterdam, remarks: esctaic 2010 IBAN:
NL30INGB0004936101
BIC: INGBNL2A
voor nederlandse betalingen : ING Rekeningnummer: 4936101 t.n.v. bovengenoemde Stichting te
Amsterdam o.v.v. esctaic 2010
You will receive confirmation by email, after receiving your payment we will send you
a receipt per email. A printed document will be issued at the congress.
Comments: