CERUMO Registration Form .pdf
Original filename: CERUMO_Registration_Form.pdf
Title: Iscrizione Gallucci
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CUTTING EDGE ROBOTIC UROLOGY & MEDICAL ONCOLOGY
Rome, June 23-24 2016
Please fill out this Registration Form using capital letters only and send it back preferably via
e-mail to email@example.com or firstname.lastname@example.org , or via Fax to + 39 0832 304994.
State (America Only)
Date Of Birth
Place Of Birth
The Registration Fee is €244,00 including VAT/IVA. It includes:
• Full Access to the Course;
• Official Certificate of Attendance;
• Access to all Coffee Breaks and Lunches.
Please carry out all payments via Bank Transfer to:
Bank Name: Banca Sella
Bank Address: Viale Guglielmo Marconi, 45
Bank City: Lecce
Bank ZIP Code: 73100
Bank Country: Italy
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