CONGRESS REGISTRATION FORM Please return by

CONGRESS REGISTRATION FORM
Please return by November, 20, 2015 at the latest!
Please complete in CAPITAL LETTERS & return to: AMSOS 2015, c/o Vienna Medical Academy, Alser Straße 4, 1090 Vienna, Austria,
Fax: +43 1 407 8274, E-mail: [email protected]
________________________________________________
LAST NAME
_________________________________________
FIRST NAME
________________________
Title
ÖÄK-Arztnummer (z.B. 12345-67):
The indication of the ÖAK-Number is mandatory in order to receive the applied DFP-points for the congress online. (Only for Austrian Doctors!)
_____________________________________________________________________________________________________________________
Institution/Hospital
_____________________________________________________________________________________________________________________
Department/Function
_____________________________________________________________________________________________________________________
Address
____________________________
ZIP Code
_______________________________________
City
_____________________________________________
Country
_________________________________________
(Mobile) Phone
_________________________________________________________________________
E-MAIL
REGISTRATION FEES (in EURO) within receipt of payment(!):
The reduced registration fee is only applicable, if it has been credited to the congress account before the respective deadline. Registering before the deadline without performing an actual
payment is not sufficient to benefit from the reduction. Please note that a different fee applies for onsite payments and registrations.



Members (EMSOS or AMSOS)
Non-Members
Students*
50,100,0,-
*only valid with a student's ID, or with confirmation from the department.
Lunchbox:
(yes or no)
Lunchbox included in the fee
Dec. 7, 2015
PAYMENT MODALITIES:
 Bank transfer, free of charges for the beneficiary, Bank account: „WMA-AMSOS 2015“,
IBAN: AT 23 20111 295 331 080 64, BIC: GIBAATWWXXX, at the „Erste Bank“, Vienna
Please do not perform bank transfers after Nov.27, 2015 and please bring a proof of payment to the onsite registration. Onsite payments is only possible in cash (EUR)
 Credit Card:
 Visa
 Mastercard
Credit Card No.:
 Diners Club
CVV2/CVC2 Code*:
Credit Card Holder:
Expiration Date:
Signature:
*The CVV2/CVC2 is a 3-digit security code printed on the back side of your card. The number appears in reverse italic at the top right end of the signature panel behind the
last 4 digits of your card number. This helps us to fight fraud in the “card-not-present transactions”. Thank you!
Date:
Signature:
You will receive written confirmation of registration by mail when the registration form has been received. Furthermore you will receive a written confirmation of payment when
the payment has been credited to the congress account. Kindly note that payments made within 2 weeks prior to the conference cannot be confirmed in writing. If you made a
bank transfer within this period, it will be essential to bring a proof of payment of your registration fee, when collecting the registration material.
After Dec. 1, 2015, pre-registration will be closed, but you may register at the "On-site registration Desk" in Vienna.
Cancellations: Please note that cancellation
1090 Vienna, Austria. The following rules apply:
have
to
be
made in written to AMSOS
- before Nov 3, 2015: 50% refund
- after Nov. 3, 2015: no refund
2015
c/o
Vienna
Medical
Academy,
Alser
Straße
4,

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