EuroPharm Forum: On-line Registration Form

17th Annual Meeting of the EuroPharm Forum

Copenhagen, Denmark
2-4 October 2008

Recommended deadline for registration:
22 August 2008 (accommodation guaranteed for registrations submitted by this date)

Asterisk (*) indicates a required field

PERSONAL DETAILS

* Title:

* Last name:

* First name:

* Organisation:

* Address:

* City:

Zip code:

* Country:

Phone no. (incl. country and area codes):

* E-mail address:

DETAILS REGARDING REGISTRATION

Please select as appropriate (lunches and coffees are included in fees):

Welcome Reception on 2 October at 19.00 (complimentary)

General Assembly on 3 October (Members and Observers only) (DKK 445)

Annual Meeting Dinner on 3 October at 19.00 (DKK 465)

Conference on 4 October (Member fee: DKK 445) OR ...

Conference on 4 October (Non-member fee: DKK 545)

The Conference fee is reduced if you represent a member association. To benefit from this reduction, please state the name of your association:

During the Conference on 4 October, I would like to present a country experience on:

Reimbursement (entails complimentary Dinner registration)

Non-adherence (entails complimentary Dinner registration)

DETAILS REGARDING ACCOMMODATION

Please indicate your choice of accommodation (prices per night incl. breakfast):

If you have selected a double room for shared occupancy, please state the name of your companion:

Number of nights required:

* Date (and time) of arrival:

* Date (and time) of departure:

DETAILS REGARDING PAYMENT

All amounts are payable in DKK. Please state the TOTAL amount due in DKK (registration, dinner, accommodation and breakfasts):

* I will pay by bank transfer (bank details will be provided upon registration)

I require an invoice to effect payment

To secure your hotel room, please submit your credit card details:

Type of card:

Card number:

Expiry date:

Name of cardholder:

Comments: