31st INTERNATIONAL COURSE IN ADVANCED RHINOPLASTY TECHNIQUES October 14, 15 and 16

31st INTERNATIONAL COURSE in

ADVANCED RHINOPLASTY TECHNIQUES

OCTOBER 28, 29 AND 30 - 2020

University Medical Center, Utrecht - Netherlands

Application Form for REGISTRATION 2020
SURNAME: *
FIRST NAME: *
E-MAIL: *
TELEPHONE: *
ADRES (private): *
CITY *
ZIP CODE: *
COUNTRY: *
PROFESSION: *
INSTITUTE *
POSITION: *

Specialist Resident
GENDER: *

Male Female
MEMBER: *

EAFPS ERS None
10 % Reduction TUITION FEE for EAFPS and/or ERS members (not for Dinner and Symposium)
Course with dissection

-

Course without dissection

-

Workshop

-

Symposium

-

Dinner
1750 € for Specialists

1350 € for Residents

1100 € for Specialists

800 € for Residents

650 € for Specialists

500 € for Residents

FREE for participiants Course and/or Workshop

200 € for non-participiants

90 € per person
Course with dissection Oct. 28, 29, 30

-

Course without dissection Oct. 28,29, 30

-

Workshop Oct. 30, afternoon

-

Symposium, Oct. 30, morning

-

Dinner, Oct. 29, evening
I
Course *

With dissection Without dissection No, not attending
II
Workshop *

Yes, attending No, not attending
III
Symposium (included for participants Course and/or Workshop) *

Yes, I only attend the symposium Included, I participate Course and/or Workshop
IV
Dinner (October 17- evening) *

Yes, one person Yes, two persons No, not attending
I + II + III + IV *

EUR
PAYMENT:

By direct credit transfer in Euro "in full" to ensure no commissions fees or bank charges are deducted.

Bank accout IBAN: NL43 INGB0007485706

BIC: INGBNL2A

On behalf of: Advanced Rhinoplasty - please mention your name + Rhinoplasty Course 2020

Cancellation costs 50 % before September 22nd 2020 and 100 % after.
Should be Empty: