Surname -------------------------------------- First name ----------------------

XIIIth Scientific Days of Gerontology and Gerodontology (A.I.G.) 2016 Annual Congress of the European College of Gerodontology (ECG) Paris, 3rd and 4th June 2016 "Gerodontology: 2016 Updates " Registration form Complete all sections of this registration form and send it with payment before April 15th, 2016 to: Dr Agnès Veille-Finet 152 avenue Henri Barbusse F 92700 COLOMBES Mobile : 00 33 6 08 75 43 17 Email : [email protected]

Surname -------------------------------------- First name ------------------------------------Profession Academic Degree ----------------------------------------------------------------Address ----------------------------------------------------------------------------------------------Postal code ------------- City ————------------------Country———------------------Phone 00 ---------------------------------------- Mobile ---------------------------------------Email -------------------------------------------------------------------------------------------------

Early registration before March 5 2016

th

After March 5th 2016

member (A.I.G. or ECG.)

☐ 300 €

☐ 350 €

no member (A.I.G. or ECG.)

☐ 400 €

☐ 450 €

Nurse and caregiver staff

☐ 150 €

☐ 175 €

Student

☐ 50 € without lunch

☐ 70 € without lunch

Membership A.I.G Membership E.C.G.

☐ 55 € ☐ 75 €

comprises 4 issues of Gerodontology.

Friday night congress dinner

☐ 75 € X …. =

€

The registration form includes scientific and social programs, abstract book, participation in all sessions, breaks and lunch. Payment can be made by bank transfer to AIG : BNP PARIS ST MAUR FOSSES (00179) BIC : BNPAFRPPCRT IBAN: FR76 3000 4001 7900 0000 1401 929