AUTHOR CORRESPONDENCE ADDRESS

Please type in capital letters and write names as they are to appear on your name badge
* FIRST NAME
* LAST NAME
ADDRESS home address institution
 INSTITUTION
DEPARTEMENT
* ADDRESS
* POSTAL CODE
* CITY
* COUNTRY
 PHONE
 FAX
* E-mail
Accompanying
Persons
1
2
3
4
5

Acknowledgement of registration and of receipt of payment will only be sent when the registration form and the payment in full are received.

Registration Fee
  amount
amount
Pre-registration (Before October 05, 2002)
 45 euro
total
EUR
Payment at the venue
 60 euro

Payment
Bank transfer into account number 123-6866199-90 of ‘Symposium Practical Urology at Klina’ Bank address: BMOV, Trieststraat 99, 9960 Assenede
Eurocard Visa Amexco Diners
 
 CC Number
 
 Expiry Date
 (mm/jj)
 
 Date
 (dd/mm/jj)

Please clearly mention the participant's name on all money transfers.
All payments must be free of charges to the receiver.