Cytoreductive Surgery in Advanced OVARIAN CANCER Any Boundaries? 13th ‐ 14th October 2014 Registration instructions 1. 2. Please print the registration form, fill it out and send it via email ([email protected]) or fax (+39 02 6686699) The Secretariat will acknowledge receipt of your registration. REGISTRATION FORM Last name: First name: Specialty: Company / Institute: Department: Address: City: Post code: Date of birth: Country: Place of birth: Codice Fiscale: VAT No.: (Italians only): (if applicable for invoice) Tel: Fax: Email: Registration fees €430,00 (including 22% VAT) Early registration fee – until September 30, 2014 €500,00 (including 22% VAT) After October 1, 2014 €200,00 (including 22% VAT) for fellows and residents in training PAYMENT BY: bank transfer OR credit card Bank transfer to the order of MZ Congressi srl: Credit Card: Visa C/C No. Card holder’s signature c/o Banca Intesa Sanpaolo - via C. Farini 56 - 20159 Milano IBAN: IT 47 V 03069 09474 000011960146 Swift: BCITITMMXXX Mastercard American Express Expiration date Card holder’s name I authorize MZ Congressi and the European Institute of Oncology to handle my personal data according to the Italian Privacy Law 196/03. Signature: Date: Esagon @ European Institute of Oncology E [email protected] W www.ieo.it/esagon_uk
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