myograd 7th Summer School for Myolog Berlin Summer School, 13

myograd 7 th Summer School for Myology
Berlin Summer School, 13 –17 June 2016
REGISTRATION
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2
myograd 7 th Summer School for Myology
Berlin Summer School, 13 –17 June 2016
PAYMENT DETAILS
THE REGISTRATION FEE OF 350 EURO COVERS TEACHING MATERIAL, LUNCH AND COFFEE BREAKS, AND THE SOCIAL PROGRAM.
PAYMENT CAN BE MADE
EITHER BY BANK TRANSFER TO
DEUTSCHE KREDITBANK
BANKLEITZAHL/SORTING CODE:
KONTO-NR. / ACCOUNT NUMBER:
IBAN:
VERWENDUNGSZWECK/REFERENCE:
120 300 00
15 12 359
DE11 1203 0000 0001 5123 59
BIC/SWIFT: BYLADEM1001
200494 (MYOGRAD SUMMER SCHOOL)
_____________________
_____________________
_____________________
PLACE
DATE
SIGNATURE
OR BY CREDIT CARD (PLEASE USE THE ATTACHED FORM).
CHARITÉ - UNIVERSITÄTSMEDIZIN BERLIN
Gliedkörperschaft der Freien Universität Berlin und der Humboldt-Universität zu Berlin
Lindenberger Weg 80 ⏐ 13125 Berlin ⏐ Telefon +49 30 450 540540 ⏐ www.charite.de
Berliner Sparkasse⏐ IBAN: DE22100500002050005515 ⏐ BIC: BELADEBEXXX
USt-Identifikationsnummer: DE 228847810 | Steuernummer: 29 / 332 / 04001
myograd 7 th Summer School for Myology
Berlin Summer School, 13 –17 June 2016
CREDIT CARD FORM
PLEASE USE THIS FORM TO PAY THE REGISTRATION FEE FOR THE 7
BY CREDIT CARD.
TH
BERLIN SUMMER SCHOOL FOR MYOLOGY
YOUR DATA NAME OF PARTICIPANT
CREDIT CARD TYPE
VISA CARD
AMOUNT TO PAY
EURO
MASTER CARD
NAME OF CREDIT CARD HOLDER
CREDIT CARD NUMBER
MONTH:
VALID THROUGH
YEAR:
CVC SECURITY CODE*
*THE
CARD VERIFICATION CODE (CVC) IS A THREE-DIGIT SECURITY CODE. YOU WILL FIND THIS CODE ON THE BACK OF YOUR
CREDIT CARD.
PLEASE FILL OUT THIS FORM, PRINT IT, SIGN IT AND SEND IT BACK EITHER BY FAX OR EMAIL OR POST IT TO:
SUSANNE WISSLER,
MYOGRAD OFFICE
CHARITÉ – UNIVERSITÄTSMEDIZIN BERLIN,
CAMPUS BUCH
LINDENBERGER WEG 80
13125 BERLIN, GERMANY
FAX: +49 30 450 540914
EMAIL: [email protected]
WITH YOUR SIGNATURE YOU
ACCEPT
THAT THE AMOUNT INDICATED ABOVE WILL BE DEBITED FROM YOUR CREDIT CARD ACCOUNT TO REGISTER FOR THE
SUMMER SCHOOL FOR MYOLOGY
7TH BERLIN
ACCEPT
THAT FEES CHARGED BY THE ISSUING BANK OF YOUR CREDIT CARD FOR MONEY CONVERSION FROM FOREIGN CURRENCIES
WILL NOT BE PAID BY THE REMITTEE.
_____________________
PLACE
_____________________
DATE
_____________________
SIGNATURE
CHARITÉ - UNIVERSITÄTSMEDIZIN BERLIN
Gliedkörperschaft der Freien Universität Berlin und der Humboldt-Universität zu Berlin
Lindenberger Weg 80 ⏐ 13125 Berlin ⏐ Telefon +49 30 450 540540 ⏐ www.charite.de
Berliner Sparkasse⏐ IBAN: DE22100500002050005515 ⏐ BIC: BELADEBEXXX
USt-Identifikationsnummer: DE 228847810 | Steuernummer: 29 / 332 / 04001

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