EuroPharm Forum

Asterisk (*) indicates a required field

PERSONAL DETAILS

* Title:

MrMs

* LAST name:

* First name:

* Organisation:

* Address:

* City:

Zip code:

* Country:

Phone no. (incl. country and area codes):

* E-mail address:

CONFERENCE DETAILS

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

EITHER select the full package of the Training Seminar:

I will attend the 2-day seminar, welcome reception 19/4 and dinner 20/4 (members only: € 350)

I will attend the 2-day seminar, welcome reception 19/4 and dinner 20/4 (non-members: € 400)

OR if you do not attend all parts of the Training Seminar, please fill in as appropriate:

I will attend the Welcome Reception on 19/4 (€ 50)

I will attend the Training Seminar, one day (members: € 175)

I will attend the Training Seminar, one day (non-members: € 200)

I will attend the dinner on 20/4 (€ 80)

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

ACCOMMODATION DETAILS

* Please indicate your choice of accommodation at the Mercure Budapest City Center :

Please selectStandard single room, 1 night (19 April) incl. breakfast and taxes: € 75Standard single room, 1 night (20 April) incl. breakfast and taxes: € 75Standard single room, 2 nights (19-20 April) incl. breakfast and taxes: € 150Standard double room, 1 night (19 April) incl. breakfast and taxes: € 92Standard double room, 1 night (20 April) incl. breakfast and taxes: € 92Standard double room, 2 nights (19-20 April) incl. breakfast and taxes: € 184No accommodation required

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

If you require further of fewer nights' accommodation, please specify:

I require 1 extra night's accommodation on:

Comments regarding accommodation:

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:

Training Seminar (2 days, incl. welcome reception 19/4 and dinner 20/4 (members) € 350

Training Seminar (2 days incl. welcome reception 19/4 and dinner 20/4 (non-members) € 400

Training Seminar one day (members) € 175

Training Seminar one day (non-members) € 200

Welcome reception 19/4 € 50

Dinner 20/4 € 80

* TOTAL payment (fees and accommodation, incl. extra nights) in €:

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

Yes

I require an invoice to effect payment

Comments: