IX FORESIGHT TRAINING COURSE

“EUROPE LEADS THE BEST MEDICINES SYSTEM FOR PATIENTS”

Pavia, 27-29 October 2016

APPLICATION FORM

Please return the form to GIANNI BENZI PHARMACOLOGICAL RESEARCH FOUNDATION within 21st Oct 2016

by email:

Name / Surname
Date and Place of birth
Address
Post code / Town / Country
Tel. / Mobile / Email
Organisation
Job title
Address of Organisation
Post code / Town / Country
Tel. / Fax / Email
Taxpayer number / VAT number
Full Course
> 30 years / < 30 years
Standard fee / EUR 800.00* / EUR 650.00*
Standard fee before 30th Sept. 2016 / EUR 750.00* / EUR 600.00*
SIAR, SSFA and AICRO Members / EUR 650.00* / EUR 500.00*
Students (Master courses, PhD; provide details in attachment to this form) / EUR 500.00*
Method of Payment
Bank transfer to: Fondazione per la Ricerca Farmacologica Gianni Benzi Onlus
IBAN code: IT57D0312704000000001001931 – BIC / SWIFT code: BAECIT2B
*Exempt from VAT as provided by article 10 (D.P.R. 633/1972)
Date / Signature
PRIVACY
In conformity with the Italian Legislative Decree n. 196, art. 13 of 30 June 2003, the Gianni Benzi Foundation informs you that the collected personal data will be handled for organisational purposes related to this event and will be by no means released to third parties. Moreover, the collected personal data can be handled for sending you free of charges the documentation related to other congresses or initiatives organised by the Gianni Benzi Foundation only. As provided by art. 7 of the Decree n. 196, art. 13 of 30 June 2003, you can contact Gianni Benzi Foundation for further information (crossing out, correction, integration of data). If you agree, please give us your authorisation.
I authorise the handling of my personal data for the above mentioned aim(s):
YES, for the IX FTC purposes only (mandatory) / YES, I also want to receive information on future courses and events organised by the G. Benzi Foundation
Date / Signature