Please Complete This Form Clearly and Accurately to Avoid Any Errors

Please complete this form clearly and accurately to avoid any errors.

Title:Click here to enter text.

First Name:Click here to enter text.

Last Name:Click here to enter text.

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Please choose your category

Full Participant – ESRA member (early fee, until 29 January 2017)EUR 625☐

Full Participant – ESRA member (late fee, after 29 January 2017)EUR 725☐

Full Participant – Non-member (early fee, until 29 January 2017)EUR 725☐

Full Participant – Non-member (late fee, after 29 January 2017)EUR 835☐

Trainee/Resident (for ESRA members only, you can purchase an ESRA membership Trainees Category for EUR 35 on ) EUR 515 ☐

ESRA Trainee/Resident (late fee, after 29 January 2017) EUR 595☐

Both Workshops - Full Participant – ESRA member (early fee, until 29 January 2017)EUR 975☐

Both Workshops - Full Participant – ESRA member (late fee, after 29 January 2017)EUR 1’125☐

Both Workshops - Full Participant – Non-member (early fee, until 29 January 2017)EUR 1’025☐

Both Workshops - Full Participant – Non-member (late fee, after 29 January 2017)EUR 1’185☐

PAYMENT

Bank transfer – please ensure that “MAD Workshop” and the name of the participant are clearly marked on the transfer. If payment is for more than one person or by a company, please make sure all names are indicated. Please send a copy of this form together with a copy of the bank transfer to the address below. Please make drafts payable to: “Ultradissection Group”and send them to BANCOPOPULAR RIOGENIL street, 17 28934 MOSTOLES - MADRID, Spain, IBAN- N°: ES09 0075 1007 74 0700257080- BIC/Swift Bank Identification Code (BIC):POPUESMM

All bank charges are the responsibility of the payee and should be paid at source.

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Date: Click here to enter a date.