Warning: Undefined variable $SERVER_PORT in /www/doc/www.conferencepartners.cz/www/chelators/forms/reg_form.php on line 5

Warning: Undefined variable $HTTP_HOST in /www/doc/www.conferencepartners.cz/www/chelators/forms/reg_form.php on line 10

Warning: Undefined variable $SCRIPT_NAME in /www/doc/www.conferencepartners.cz/www/chelators/forms/reg_form.php on line 10

Warning: Undefined variable $QUERY_STRING in /www/doc/www.conferencepartners.cz/www/chelators/forms/reg_form.php on line 10

Warning: Cannot modify header information - headers already sent by (output started at /www/doc/www.conferencepartners.cz/www/chelators/forms/reg_form.php:5) in /www/doc/www.conferencepartners.cz/www/chelators/forms/reg_form.php on line 10

Warning: Cannot modify header information - headers already sent by (output started at /www/doc/www.conferencepartners.cz/www/chelators/forms/reg_form.php:5) in /www/doc/www.conferencepartners.cz/www/chelators/forms/reg_form.php on line 11
Chelators 2004 REGISTRATION FORM
7th Internationl Symposium on Chelating Agents in Biomedicine, Toxicology and Therapeutics, July 8 - 11, 2004, Pilsen, Czech Republic
   REGISTRATION FORM
 
First Name
 Family Name
 Title
Mailing Address
Zip Code
 City
 Country
Phone
 Fax
 E-mail
Accompanying Person/s
I REGISTER FOR THE SYMPOSIUM AND PAY THE REGISTRATION FEE
– SELECT THE PROPER OPTION/S:
 
Payment (EUR)
Delegates (advanced registration fee 250 EUR)
Delegates (late registration fee 300 EUR)
Accompanying person (registration fee 100 EUR)
Publishing in Proceedings (50 EUR)
I WILL ATTEND THE FOLLOWING SOCIAL EVENTS:
No. of tickets
Payment (EUR)
* Trip (July 9, 2004)
incl. in the reg. fee
* Symposium dinner (July 10, 2004)
incl. in the reg. fee
TOTAL PAYMENT:
I pay by bank transfer. Copy of the bank draft of amount of   EUR is send by mail or by fax to the Symposium Secretariat.
  Bank account No.: 176970780/0300 of the Conference Partners Prague
at the Československá obchodní banka, a.s., Anglická 20, 120 00 Prague 2, Czech Republic.
SWIFT CODE: CEKO-CZ-PP, IBAN CODE: CZ6403000000000176970780
 
I authorize the Conference Partners Prague to charge the total payment of   EUR to my credit card:
 
VISA     Eurocard/Mastercard
Card holder’s name (as appears on card)
Card No.
 Expiry date
 CVC code*
(* CVC code are the last three figures which are on the top of the signature strip on the back side of the card)