REGISTRATION FORM – Clinical correlations in cardiomagnetic resonance

REGISTRATION FORM
Clinical correlations in cardiomagnetic resonance
Surname:	*	Name:	*
Instittution:	*
Address:	*	Postcode/City/Country:	*
E-mail:	*	Contact phone:	*
Mobile phone:
*Required fields!

REGISTRATION FEE
Registration Fee for doctors:	100 EUR REG_FEE_FOR_DOCTORS: YES
Registration Fee for nurses:	50 EUR REG_FEE_FOR_NURSES: YES


MODE OF PAYMENT - BANK ACCOUNT
Institution or Personal name		VAT:
Address/City/Country:		E-mail:


IMPORTANT NOTE! All prices are in EUR. After receipt of the registration form, the executive organizer will send the proforma invoice with deadline for payment.
Deadline to send Registration form is February 28th, 2019.
I agree with the terms of participation to the Symposium.* I agree with the terms of participation to the Symposium.