Conference Bariatric 2017

REGISTRATION FORM

Bariatric Conference in Kcm Clinic, Jelenia Góra, 28th of October 2017. After sending registration form you'll recieve email with confirmation of registration.
Full Name*

PrefixFirst NameLast Name
Specialization
Address*

Street Address

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail*
Suggestions or special questions/requests
Participants are entitled to a certificate and educational points.

If you have any questions about conference or need help with registration, please contact us:

Natalia Szwed, Mobile: + 48 533375111,
E-mail: info@kcmclinic.pl konferencja@kcmclinic.pl

Participation fee: 200 PLN

Please transfer your payment with title "NAME, BARIATRIC CONFERENCE 2017" to one of following bank accounts:

KCM Clinic S.A.
Bankowa 5-7, 58-500 Jelenia Gora, Poland

for PLN (IBAN): PL44191010482403384858130001
Kod BIC (SWIFT): DEUTPLPX

for EUR (IBAN): PL17191010482403384858130002
Kod BIC (SWIFT): DEUTPLPX

for GBP (IBAN): PL60191010482403384858130004
Kod BIC (SWIFT): DEUTPLPX

for USD (IBAN): PL87191010482403384858130003
Kod BIC (SWIFT): DEUTPLPX
Should be Empty:

REGISTRATION FORM