Registration form GAVeCeLT 2019

Personal data

Given name

Place of birth Date of birth

Street address

ZIP code City

State Phone email

Hospital/Institution Profession

Data for the invoice

Address

Congress

Secretariat

Millennium Events srl Via Konrad Adenauer, 18 00061 Anguillara Sabazia (RM) P.IVA e C.F. 13091811003 T + 39 06 01902533 F + 39 06 3221853 [email protected]

Payment

Money transfer to: Millennium Events

Bank: Banca Popolare dell’Emilia Romagna - Roma Succursale I

IBAN: IT07Z0538703209000002290962

BIC/SWIFT: BPMOIT22XXX

date signature

Scientific Events

Dec 2

₍

_afternoon)

₊

_{Dec 3}

₍

_{all day)}

11

_{GAVeCeLT Congress}

Dec 3

₍

_{all day)}

2

_{GAVePed Conference}

Dec 4

₍

_{all day)}

13

_{PICC Day}

Registration

Registration to 1 event

€ 350 + iva (€ 77)

❍

GAVeCeLT Congress

❍

GAVePed Conference

❍

PICC Day

Registration to 2 events

€ 600 + iva (€ 132) € 650 + iva (€ 143)

❍

GAVeCeLT Congress + PICC Day

❍

GAVePed Conference + PICC Day

Registration

Form

Please complete this form and forward it by e-mail or fax to Millennium Events, including a copy of your money transfer.

GAVeCeLT

Verona

December 2

_{- 3}

_{- 4}

2019