Chair of Epidemiology
and Preventive Medicine
Department of Medical Sociology / European Society
for Health and Medical Sociology
Eleventh ESHMS International Congress
August 31 - September 2, 2006Krakow, Poland
REGISTRATION FORM
Please print this form, complete it and fax or mail it to:
The JagiellonianUniversity Events Office24 Gołębia Street
31-007 Kraków
Poland
Fax/phone: +48 /12/ 663 38 58
E-mail:Family name ______First name ______□ Male □ Female
Complete correspondence address Street ______
Postal code ______City ______Country ______
Phone ______Fax ______
E-mail (please use capital letters) ______
Name(s) of accompanying person(s) if any ______
REGISTRATION FEES*
Before 31 May 2006 / After 31 May 2006ESHMS Members ** / € 250,00 / € 300,00
Non-Members / € 320,00 / € 370,00
Participants from Central and Eastern Europe/Students
/ € 100,00 / € 150,00* The enrollment fee includes participation in the Congress, the social programme and all materials. Registration can only be confirmed following receipt of payment.
** Only those individuals who have paid their ESHMS Membership Fee will qualify for the reduced registration fee. We encourage you to support your Society by joining for a 2-year period to coincide with our Congress cycle and ensure that you receive early notification of the next Congress and any seminars/workshops. For a membership form (and the option of paying by BACS transfer) please use the following link:
Accompanying person fees (optional)
Welcome reception / € 25,00Social dinner / € 45,00
Cancellation policy
Refund policy for registration fee is as follows:
Cancellation after July 30, 2006 no refund
Cancellation must be conferred in writing; all refunds will be processed after the Congress
Social programme
Please see details on the social programme on the website
Special requirements
Mobility or other disability related needs (please indicate…………………………………..)
Vegetarian food or other dietary needs (please indicate…………………………………….)
Other (please indicate………………………………………………………………………)
TOTAL AMOUNT TO BE PAID:
Registration feeAccompanying person
Total
PAYMENT CAN BE MADE AS FOLLOWS:
Fee should be made payable to theJagiellonianUniversity – ESHMSand should be sent to:
Jagiellonian University BOI, ul. Gołebia 24, 31-007 Krakow, Poland
Please indicate which of the following means of payment you wish to use:
(In case of bank transfer, please cover the banking charges).
Bank transferto:
Jagiellonian University BOI, Bank: BPH S.A. O/Kraków, Account number:
IBAN: PL 75 1060 0076 0000 3300 0015 7610, SWIFT: BPHK PL PK
(please give the reference ‘ESHMS/registration fee’, as well as the name of the participant. Do not forget to bring a copy of a document confirming your payment).
Credit card
I authorise the JagiellonianUniversity Events Office to charge the amount of EUR ………….. to the following credit card:□ Eurocard/Mastercard □ JCB Card □ Visa □ American Express □ other
Card number ______/ ______/ ______/ ______
Expiry date: ______/ ______(month/year)
Name of cardholder ______
Billing address ______
Signature ______Date ______
Date ______Signature ______
INVOICE REQUEST
Please draw an invoice with VAT included.
Please note that the invoice can be drawn only to the remitter.
Charge to:
Institution: ......
......
Address: ......
......
VAT number: ......
Amount: ......
Invoice should be dispatched to: ......
......
Signature: ......
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