Magyar Imre EASD Clinical Postgraduate Course 2016

Only fields marked * are mandatory!

IMPORTANT!

As the number of the participants is limited, the acceptance of the application will be confirmed by the Local Organizing Committee via email.

The organizers cover the costs of hotel stay with breakfast (two nights on 17/18 and 19/20 November in shared rooms), meals from lunch on 17th November to lunch on 19th November as well as scientific materials, but do not cover travel and parking costs, minibar, telephone, wellness and other extra services.

Single occupancy cost: 75 EUR/participant/night
Extra nights:
- single room: 150 EUR/night
- double room shared with other participant: 75 EUR/person/night

Please note, that the extra amount for single occupancy, extra nights and meals needs to be paid by the participants themselves! Bank account details will be found in the confirmation e-mail.

Prefix (Ms., Mrs., Mr., Dr. etc.)*
First name*
Middle initial
Last name*
Gender*	Male Female
Brief affiliation how it should occur on badge
Organization/Company*
Department
Address*
Address (City)*
Address (Country)*
Zip/Postal code*
Primary phone (Please enter your country code, area code and phone number with no dashes or spaces)*
Mobile phone (For emergency onsite use only)
Passport/ID number*
Date and place of birth*
E-mail (Your e-mail is required to receive confirmation)*
Confirm e-mail*
I share the hotel room with:
I am arriving *	By rail By plane By coach By car Other
Date and time of arrival*
Date and time of departure*
Vegetarian diet required	Yes No
Other requests

Single occupancy cost: 75 EUR/participant/night
Extra nights:
- single room: 150 EUR/night
- double room shared with other participant: 75 EUR/person/night