Please print in block letters, sign and fax, e-mail or airmail to the
address below. Form may also be downloaded, www.vitalmedbodrum.com
Family name First
name Title,
Mr/Ms
Institute Dept.
Street City Country
Telephone (office hours) Fax
E-mail address
Discipline
1. Specialist (pls. specify)
2. Therapist (pls. specify)
3.
Assistant/trainee (pls. specify)
4. Other (pls. specify)
Registration
Fees, pls. tick the appropriate box
|
|
Until August
15, 2007 |
From August
16 to October 20, 2007 |
On Site |
|
Medical
doctors/Therapists |
ÿ Euro 490 |
ÿ Euro 590 |
ÿ Euro 650 |
|
Assistants/Trainees |
ÿ Euro 250 |
ÿ Euro 350 |
ÿ Euro 425 |
I wish to attend the following workshop(s). Fee Euro 40 per workshop
ÿ 1. Physical examination of the hand
ÿ 2. Splinting
ÿ 3. Patient demonstrations
Accommodation,
pls. tick the requested room(s)
Accommodation, prices per room, per night, all inclusive(applicable
from 20 to 26 October 2007) |
***** Hotel
Diamond of Bodrum All Inclusive |
|
When staying
outside Diamond of Bodrum a daily
supplement of Euro 20,00 is due (includes
lunch) |
|
Single room |
ÿ Euro 70 |
|
|
|
Double room |
ÿ Euro 95 |
|
€
20 per
person per day |
|
Triple room |
ÿ Euro 130 |
|
Number of
days ( ) academic program is 4
days! |
Date of arrival: Date
of departure
NB : In the last few weeks before the course it is not certain we can book a room for participants in the Hotel Diamond of Bodrum. However, alternative hotels in the vicinity will be booked and the participants concerned will be informed. The supplement for staying in the Diamond of Bodrum during the day (Euro 20) will be paid for by the organizers.
Airport
Transfers (€ 70 pp, to
and from hotel) for …… person(s)
flight number, date and time of arrival:
flight number, date and time of departure:
Flight details
should be provided no later than 2 weeks before the event
Payments must
be made in Euro, please tick the
preferred payment:
( )
Bank transfer to
Name bank: Finansbank
Bodrum Branch 481 (Şubesi) Account name: VitalMed Ltd. Sti.
Account nr: 10665879 Euro Reference: 5th Hand 2007
Branch code:481 Swift
Code: FNNBTRISBOD
IBAN no: TR470011100000000010665879 Bank Code: 111
I authorize
you to debit my ÿ Master ÿ Visa expiry
date ……../……..
Card No.:
…..……………-…..………..….-…..………..….-…..………..….
Card Validation Code (CVC), see back of the credit card; last three digits: ……………
Name and
address of credit card holder if different from that on registration form:
Calculation of amount due
Registration fee € …..………..….
Workshops
€
... ...... ........... Signature
Hotel
/ supplement € …..………..….
Turkish night (€ 50 pp) € …..………..….
Transfers (€ 70 pp) €
…..………..….
Boat trip non-participant (€ 40 pp) € ……………….
Total amount due € …..………..….
|
Please
do not contact the hotel directly. Until 3 days prior to arrival –
full refund less handling charge of Euro 25 From 2 days prior to arrival – 1
night cancellation charge In the event of non-arrival, the
hotel will automatically release the reservation and the payment will be
non-refundable. |
Refund will
be as follows: Until and including August 15,
2007 – full refund less handling charge of Euro 25 From August 15, 2007 – 50% refund No refund on cancellations after
September 30, 2007 |
All cancellations must be faxed,
electronically mailed or post-marked to the meeting secretariat at VitalMed
VitalMed
Bodrum
Address: Davutlar sokak 13, 48400 Bodrum, Muğla, Turkey
Tel : + 90 (0)252 316 5107 Fax:
+90 (0)252 316 5143
e-mail : vitalmed@vitalmedbodrum.com www.vitalmedbodrum.com
European
office
Tel: + 32 (0)14 346028
For
questions about the contents you may also contact
Prof. dr.
H.J. Stam at h.j.stam@erasmusmc.nl