RHINOPLASTY INTERNATIONAL DISSECTION COURSE

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RHINOPLASTY INTERNATIONAL DISSECTION COURSE
RHINOPLASTY INTERNATIONAL DISSECTION COURSE
Milano, March 19th - 20th, 2016
PLEASE COMPLETE AND RETURN THE ENTIRE REGISTRATION FORM TO:
ACHELOIS Srl – Fax +39 02 2643 3754 – e-mail: [email protected]
Surname ____________________________________ Name ________________________________
Place of Birth _________________________________ Date of Birth __________________________
Home address ______________________ City ____________________Country _______________
Institute ___________________________________________________________________________
Institute Address ____________________________________________________________________
City _______________________________ Postal Code____________ Country ________________
E-mail _____________________________________________________________________________
Phone ________________________________________ Fax _________________________________
INVOICE DATA (COMPULSORY)
Heading of Invoice __________________________________________________________________
Fiscal Address ______________________________________________________________________
City _______________________________ Postal Code_____________ Country ________________
Fiscal Code (for Italians only) _________________________________________________________
VAT Nr. ___________________________________________________________________________
REGISTRATIONS
□
Registration fee
€
1.550,00 VAT 22% included
The number of places is limited and the registration will be accepted on a “first come first
served” basis.
METHODS OF PAYMENT
1. BANK TRANSFER (registration will not be processed without a copy of the transfer)
ACHELOIS SRL
Bank: Banca Popolare di Bergamo
Agency: 1860 Vimercate
IBAN: IT16 H054 2834 0700 0000 0008 472 – BIC/SWIFT: BLOPIT22
2. CREDIT CARD
VISA
MASTERCARD
NAME AS ON THE CARD ________________________________________________________________
DATE OF BIRTH _______________________________
EXPIRE DATE __________________________
CREDIT CARD NUMBER ___________________________________SECURE CODE ________________
SIGNATURE ____________________________________________________________________________
CANCELLATION POLICY
Notification of cancellation must be made in writing to the Organising secretariat. All refunds will
be reimbursed only after the end of the course, by bank transfer, as follows:
▪
▪
between January 30th, 2016 and February 20th, 2016 – 50% of the paid fee
after February 20th, 2016 – no refund
According to the Italian Law nr. 196/03 on privacy protection, your data will be treated by Achelois Srl (Via Larga, 8 –
Milano). At any time you can ask to modify or cancel your data. In absence of authorization we will not proceed with
your registration to the congress.
DATE ___________________________________________ SIGNATURE _________________________________