Registration Form ESIR 2015
Registration Form ESIR 2015 - Expert Courses
Critical Limb Ischaemia Diagnosis, Treatment and Parameters for Success
Amsterdam (NL), October 16-17, 2015
Prostate Embolisation
Milan (IT), October 29-30, 2015
Effective Hepatocellular Lausanne (CH), November 13-14, Carcinoma (HCC) Treatments - 2015 Advanced Local Therapies
The Future of Image-Guided Tumour Ablation - Targeting Techniques and High-End Clinical Strategies
Neutorgasse 9/6 AT - 1010 Vienna Phone: 0043 1 904 2003 Fax: 0043 1 904 2003 30 www.cirse.org mailto: [email protected]
Innsbruck (AT), December 11-12, 2015
Please complete legibly and send by email to the CIRSE Central Office. I need an invitation letter for visa application
Date of Birth: .....................................................................................................
Female
Prof. / Dr. / Mr. / Mrs. / Ms. (please indicate)
Male
CIRSE ID: ...................................................................................... Family Name: ............................................................................... First Name: ......................................................................................................... Institution: ................................................................................................................................................................................................................. Street / no: ................................................................................................................................................................................................................. City: .............................................................. Post Code: ................................ Country: .......................................................................................... Phone: .......................................................................................... Fax: ..................................................................................................................... Email: ......................................................................................................................................................................................................................... Registration Fees (fees refer to one course) Early Registration Fees (until 8 weeks prior to the course date)
Late Registration Fees (after 8 weeks prior to the course date)
CIRSE Member EUR 280 ESR Member** EUR 280 Non-Member EUR 420 Resident/Nurse/Radiographer Member* EUR 210 Resident/Nurse/Radiographer Non-Member* EUR 280
CIRSE Member EUR 380 ESR Member** EUR 380 Non-Member EUR 520 Resident/Nurse/Radiographer Member* EUR 310 Resident/Nurse/Radiographer Non-Member* EUR 380
* registration needs to be accompanied by a confirmation, signed by the head of department. ** registration needs to be accompanied by a certificate, confirming the participants’ ESR Membership.
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Cancellation Insurance: YES NO Early Insurance Fees (until 8 weeks prior to the course date)
Late Insurance Fees (after 8 weeks prior to the course date)
CIRSE Member EUR 20 ESR Member EUR 20 Non-Member EUR 29 Resident/Nurse/Radiographer Member* EUR 15 Resident/Nurse/Radiographer Non-Member* EUR 20
CIRSE Member EUR 27 ESR Member EUR 27 Non-Member EUR 36 Resident/Nurse/Radiographer Member* EUR 22 Resident/Nurse/Radiographer Non-Member* EUR 27
The CIRSE Foundation offers all participants the possibility of purchasing insurance with our partner, "Europäische Reiseversicherung". Thus, the CIRSE Foundation itself will not refund any amount after a cancellation of registration. All requests have to be issued to the "Europäische Reiseversicherung" directly. Refunds will be given within the terms and conditions of the "Europäische Reiseversicherung". For further questions or information, please read the general terms and conditions which can be found on our website at www.cirse.org or contact [email protected]. Please note that CIRSE offers just a platform to effect a policy between you and "Europäische Reiseversicherung".
Payment Bank Transfer IBAN: BIC: Bank Name: Account Name: Please indicate:
AT832011128564548000 GIBAATWW Die ERSTE Bank (20111) The CIRSE Foundation First Name, Last Name, Course
Please note that registrants are responsible for any bank charges that may occur. If the amount transferred to the CIRSE Foundation account does not correspond to the amount stated on the registration form, your registration will be regarded as incomplete. Please note that your registration becomes valid only after receipt of payment before the applicable deadline and after confirmation by the CIRSE Central Office.
Credit Card Visa
Euro / MasterCard
Credit Card no.: ………………. / ………………. / ………………. / ……………….
CVV2 Code: ……………………
Expiry Date: …… / …… Card holder’s name: …………………………………………. Card holder’s signature: ……………………...........
I accept the general terms & condition for the ESIR 2015 courses
Date: ............................................................................................ Signature: ...........................................................................................................
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Critical Limb Ischaemia Diagnosis, Treatment and Parameters for Success
Amsterdam (NL), October 16-17, 2015
Prostate Embolisation
Milan (IT), October 29-30, 2015
Effective Hepatocellular Lausanne (CH), November 13-14, Carcinoma (HCC) Treatments - 2015 Advanced Local Therapies
The Future of Image-Guided Tumour Ablation - Targeting Techniques and High-End Clinical Strategies
Neutorgasse 9/6 AT - 1010 Vienna Phone: 0043 1 904 2003 Fax: 0043 1 904 2003 30 www.cirse.org mailto: [email protected]
Innsbruck (AT), December 11-12, 2015
Please complete legibly and send by email to the CIRSE Central Office. I need an invitation letter for visa application
Date of Birth: .....................................................................................................
Female
Prof. / Dr. / Mr. / Mrs. / Ms. (please indicate)
Male
CIRSE ID: ...................................................................................... Family Name: ............................................................................... First Name: ......................................................................................................... Institution: ................................................................................................................................................................................................................. Street / no: ................................................................................................................................................................................................................. City: .............................................................. Post Code: ................................ Country: .......................................................................................... Phone: .......................................................................................... Fax: ..................................................................................................................... Email: ......................................................................................................................................................................................................................... Registration Fees (fees refer to one course) Early Registration Fees (until 8 weeks prior to the course date)
Late Registration Fees (after 8 weeks prior to the course date)
CIRSE Member EUR 280 ESR Member** EUR 280 Non-Member EUR 420 Resident/Nurse/Radiographer Member* EUR 210 Resident/Nurse/Radiographer Non-Member* EUR 280
CIRSE Member EUR 380 ESR Member** EUR 380 Non-Member EUR 520 Resident/Nurse/Radiographer Member* EUR 310 Resident/Nurse/Radiographer Non-Member* EUR 380
* registration needs to be accompanied by a confirmation, signed by the head of department. ** registration needs to be accompanied by a certificate, confirming the participants’ ESR Membership.
1/2
Cancellation Insurance: YES NO Early Insurance Fees (until 8 weeks prior to the course date)
Late Insurance Fees (after 8 weeks prior to the course date)
CIRSE Member EUR 20 ESR Member EUR 20 Non-Member EUR 29 Resident/Nurse/Radiographer Member* EUR 15 Resident/Nurse/Radiographer Non-Member* EUR 20
CIRSE Member EUR 27 ESR Member EUR 27 Non-Member EUR 36 Resident/Nurse/Radiographer Member* EUR 22 Resident/Nurse/Radiographer Non-Member* EUR 27
The CIRSE Foundation offers all participants the possibility of purchasing insurance with our partner, "Europäische Reiseversicherung". Thus, the CIRSE Foundation itself will not refund any amount after a cancellation of registration. All requests have to be issued to the "Europäische Reiseversicherung" directly. Refunds will be given within the terms and conditions of the "Europäische Reiseversicherung". For further questions or information, please read the general terms and conditions which can be found on our website at www.cirse.org or contact [email protected]. Please note that CIRSE offers just a platform to effect a policy between you and "Europäische Reiseversicherung".
Payment Bank Transfer IBAN: BIC: Bank Name: Account Name: Please indicate:
AT832011128564548000 GIBAATWW Die ERSTE Bank (20111) The CIRSE Foundation First Name, Last Name, Course
Please note that registrants are responsible for any bank charges that may occur. If the amount transferred to the CIRSE Foundation account does not correspond to the amount stated on the registration form, your registration will be regarded as incomplete. Please note that your registration becomes valid only after receipt of payment before the applicable deadline and after confirmation by the CIRSE Central Office.
Credit Card Visa
Euro / MasterCard
Credit Card no.: ………………. / ………………. / ………………. / ……………….
CVV2 Code: ……………………
Expiry Date: …… / …… Card holder’s name: …………………………………………. Card holder’s signature: ……………………...........
I accept the general terms & condition for the ESIR 2015 courses
Date: ............................................................................................ Signature: ...........................................................................................................
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