Lebanese Society of Neurology

Lebanese Society of Neurology

3rd International Congress of the LSN

Grand Hills Hotel & Resort, Broumana – September 22-25, 2011

Application For Reduced or Exempt Dues

Please Print in BLOCK LETTERS and Fax or E-Mail to LSN Congress Office

Tel/Fax + 961 1 429 898 – –

(Please TYPE or Type in BLOCK LETTERS)

Name……………………………………………………... First Name……………….…………………

Title Prof. Dr. Fellow/Res Mr.  Mrs. Ms.

Address……………………………………………………………………………………………………………………………………………………..…IInsitution………………………………………Country……………………..

Fax (Country Code/City Code/Number) ………………………………….....

Telephone (Country Code/ City Code/ Number)………………………….....

 I DO NOT wish my details to be forwarded to industrial companies

I will be attending the following Teaching Course on Thursday Sept. 22:

A - Teaching courses (Kindly select one course)

 Epilepsy  Dementia  Stroke

 Botulinum Toxin  ENMG  Muscle

 Fees Exempt

Course Fee………………………………………………………… 50 $

Course Fee for Resident/Fellow …………………………………  25 $

(Can be independent from Registration to Congress)

B- Registration Fees (Scientific Sessions/Lunches/Breaks/Bag/Badge)

 Fees Exempt

 Fellow/Resident (120 US$) – Supporting Doc. To be attached …………………….  120 $

 Physicians………………………………………………………  310 $

Can Contribute by the following Amount

A-  Teaching Course US$......

B-  Registration US$......

TOTAL US$......

BANK TRANSFER – With your name and address indicated on this form. If payment is made for more than one person or by company please make sure all names are indicated and send fully completed Registration and Accommodation Forms together with a copy of the bank transfer. Please make payments to:

Société Libanaise de Neurologie

A/C # 200. 0710126. 007

Banque Byblos SAL – Branche Sassine – Liban

Swift: BYBALBBX

Bank Charges are the responsibility of the participant and should be paid at source in addition to the registration and accommodation fees.

Write a few sentences to underline objectively the cause(s) of the exempt dues demand:……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Date…………………………….. Signature …………….…………………

Kindly note that 20% of the above mentioned total amount will not be refunded as the result of cancellation received before Sept 5th, 2011. Cancellation after Sept. 5nd, 2011 will not be refunded.

Form to be sent to the LSN Office

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Fax/ 01 429898 /
Telephone/ 71 573937/ 71 940943