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 _________________________________