EuroPharm Forum: Registration form

Conference and General Assembly

Copenhagen, Denmark

30 September - 2 October 2010

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

Asterisk (*) indicates a required field

PERSONAL DETAILS

* Title:

* LAST name:

* First name:

* Organisation:

* Address:

* City:

Zip code:

* Country:

* E-mail address:

CONFERENCE DETAILS

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

I will attend the 2-day conference and general assembly (members only: 150 €)

I will attend the general assembly (members only: € 75)

I will attend the 2-day conference (members only 150 €)

I will attend the 2-day conference (non-members: 200 €)

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

ACCOMMODATION DETAILS

* Please indicate your choice of accommodation at the Comfort Hotel Østerport:

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

Date of arrival

Date of departure

I require 1 extra night's accommodation on:

Comments regarding accommodation:

PLEASE NOTE that the payment for the room and any incendentals incurred during your stay shall be settled directly by you to the hotel.

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

Name of cardholder:

Type of card:

Card number:

Expiry date:

PAYMENT DETAILS

Please select your registration fee as appropriate:

Conference (2 days) and general assembly, incl. welcome reception and dinner (members) 150 €

General assembly incl. welcome reception and dinner (members only) 75 €

Conference (2 days incl. welcome reception and dinner (members only) 150 €

Conference (2 days incl. welcome reception and dinner (non-members) 200 €

* TOTAL payment (fees) in €:

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

I require an invoice to effect payment

Comments: