SYnERGYMED2019 Registration form

Registration form

Full Name*

First NameLast Name

Data

Dati

E-mail*

Phone Number*

Area CodePhone Number

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Do you bring an accompanying person with you?*

YESNo

Accompanying Person *

First nameLast Name

SyNERGYMed Author*

YESNo

Author ID#*

IEEE PES member*

YESNo

IEEE Membership ID#*

PhD Student*

YESNo

Scanned copy of an official document stating the academic position*

Browse Files

Author/Pes Member before 10/05/2019 EUR

Author/Pes Member after 10/05/2019 EUR

Non Author/Non Pes Member before 07/05/2019 EUR

Non Author/Non Pes Member after 07/05/2019 EUR

PhD Reduced registration fee EUR

Accompanying person EUR

Registration

Check out

Amount due*

Payment

PayPal/Credit CardBank Transfer

Payments are processed through PayPal. You may pay using an existing PayPal account, or any major credit card/debit card.

My Products

Conference Full-Access w/ Gala Dinner€350.00

Registration fee

Accompanying person€50.00

Total €0.00

Payment Method
Credit	Express

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year
Billing Address
Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Unbalance *

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SyNERGY MED 2019