CERUMO Registration Form .pdf

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Original filename: CERUMO_Registration_Form.pdf
Title: Iscrizione Gallucci

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Registration Form
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 ecm@formedica.it or digital@formedica.it , or via Fax to + 39 0832 304994.
Personal Details
Title
Family Name
First Name
Personal Address
ZIP Code
City
Country
State (America Only)
Phone
e-mail Address
Date Of Birth
Place Of Birth
Fiscal Code/Social
Security Number
IVA Number/VAT
Number
Medical Specialty
Clinic/Company

Registration Costs
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.

Payment Details

Please carry out all payments via Bank Transfer to:

Formedica Srl
IBAN: 052668696720
SWIFT/BIC: SELBIT2BXXX
Bank Name: Banca Sella
Bank Address: Viale Guglielmo Marconi, 45
Bank City: Lecce
Bank ZIP Code: 73100
Bank Country: Italy


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