EuroPharm Forum: Registration form

20th Annual Meeting and Conference of the EuroPharm Forum

Ohrid, Macedonia FYROM

14-15 October 2011

Recommended deadline for registration
(accommodation is guaranteed for registrations
submitted until 1 October)

Asterisk (*) indicates a required field

PERSONAL DETAILS

* Title:

* LAST name:

* First name:

* Organisation:

* Address:

* City:

Zip code:

* Country:

* E-mail address:

ACCOMMODATION DETAILS

* Please indicate your choice of accommodation at the hotel:

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

Please indicate your date of arrival

And your date of departure

Total number of nights:

Comments regarding accommodation:

If you have special needs (eg dietary requirements), please inform us:

To secure your room, kindly provide us with your credit card details:

Name of cardholder:

Type of card:

Card number:

Expiry date:

PLEASE NOTE THAT THE PAYMENT FOR THE ROOM AND ANY INCIDENTALS INCURRED DURING YOUR STAY SHALL BE SETTLED DIRECTLY BY YOU TO THE HOTEL.

PAYMENT DETAILS

Registration fee for the conference: 100 EUR

Registration fee for the Annual Meeting: 50 EUR

I wish arranged transport Skopje-Ohrid and return, 50 EUR

Please indicate your date and time of arrival

Please indicate your date and time of departure

I wish to participate in the Gala Dinner, Friday

I wish to participate in the City Tour, Saturday

I wish to participate in the Boat Trip, Sunday

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

*I require an invoice to effect payment

Comments: