Registration form RBSPRM 2007
Personal Information
Title  
Family Name*  
First Name *  

Organisation*

  
Department *  
Address for Correspondence *  
Postal Code/ZIP *  
City *  
Country *  
Phone
Fax
Email *  
Participants
until 30/11 of 01/12
Two Days
Member RBSPRM € 100,00 € 125,00
Non-Member € 150,00 € 175,00
European Board Certified Member € 80,00 € 100,00
Resident, Paramedic* € 65,00 € 65,00
Saturday Only
Member RBSPRM - Member NFLNRC € 50,00 € 65,00
Non-Member € 75,00 € 90,00
* Certificate confirming resident/paramedic status is obligatory: without certificate the member or non-member fee will be charged.
Please Register me as
Total 0Euro
My Payment details
Payment must accompany this registration form - Registration will only be confirmed on receipt of the full payment.
Total Amount
 0Euro
Payment

Please mention the participant’s name on all money transfers. All payments must be made without bank charges for the receiver.
Credit Card
Credit Card Holder:
Credit Card Number:
CVS Code:
Expiry Date(DD/MM/YY):
Hotel Accommodation
Please book me a
at the hotel :
Arrival Date:
Departure Date:
Do you have any dietary or other requirements?
I secure the reservation of my room with the credit card details mentioned below (obligatory)
Credit Card:
Credit Card Holder:
Credit Card Number:
CVS Code:
Expiry Date(DD/MM/YY):
Your credit card will NOT be charged by Medicongress, but only serves as a reservation guarantee.
Room and personal expenses must be paid directly to the hotel at check-out.