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EMAA 2006 - EuroMediCom

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Family Name / Nom :First Name / Prénom :Specialty / Spécialité :Address / Adresse :<strong>EMAA</strong> <strong>2006</strong>, Paris October 13-15, <strong>2006</strong>Registration form - Fiche d’inscriptionZip code / Code postal : City / Ville :Country / Pays :Tel. : Fax :E-mail :Please type in capital lettersEn lettres capitales SVPREGISTRATION FEES / Droits d’inscriptionInclude access to all sessions, workshops and commercial exhibit, coffee breaks, lunches and cocktailsoffered on site, a certificate of attendance, the conference book, a congress bag and all documentation. Delegate / Congressiste3 days / 3 jours X 13/10 X 14/10 X 15/10 430 € 490 €Delegate also registered to 1 pre-course / Congressiste inscrit à 1 pré-cours 330 € 390 €2 days / 2 jours 13/10 14/10 15/10 Please tick the day(s) 340 € 400 €1 day / 1 jour 13/10 14/10 15/10 } Cochez le(s) jour(s) 170 € 200 € Member of Scientific Society (certificate requested)Membre d’une Société Scientifique (attestation à joindre obligatoirement)3 days / 3 jours X 13/10 X 14/10 X 15/10 380 € 450 €Member also registered to 1 pre-course / Membre inscrit à 1 pré-cours 300 € 370 € Student, Nurse, Physiotherapist, Assistant (certificate requested)No registration will be validated without certificate or proofEtudiant, Infirmière, Kiné, Assistante (attestation à joindre obligatoirement) Aucune inscription ne sera validée sans l’envoi d’une attestation3 days / 3 jours X 13/10 X 14/10 X 15/10 330 € 390 €Student, RN registered to 1 pre-course / Etudiant, Infirmière inscrit à 1 pré-cours 280 € 340 €2 days / 2 jours 13/10 14/10 15/10 240 € 300 €1 day / 1 jour 13/10 14/10 15/10 Cochez le(s) jour(s) 120 € 150 € Accompanying Person (access to exhibit only + workshops)Accompagnant(e) (accès à l’exposition seulement + workshops)3 days / 3 jours X 13/10 X 14/10 X 15/10 240 € 280 €2 days / 2 jours 13/10 14/10 15/10 200 € 240 €PRE-COURSES1 day / 1 jour 13/10 14/10 15/10 Cochez le(s) jour(s) 100 € 120 € AAMS - Anti-Aging Medicine Specialization - 6-day Seminar Venue: CAP15 - 3 Quai de Grenelle 75015 PARIS6 days / 6 jours X 7/10 X 8/10 X 9/10 X 10/10 X 11/10 X 12/10 1650 € 1750 €Day rate / Prix/jour 7/10 8/10 9/10 10/10 11/10 12/10 300 € x ... day(s) = .......... €Tick the day(s) and multiply by the day rate / Cochez le(s) jour(s) et multipliez par le tarif jour Aesthetic Pre-Course FACE AND BODY (lunches included)Student Member Non Member Student Member Non Member2 days / 2 jours X 11/10 X 12/10 Venue: CAP15 - 3 Quai de Grenelle 650 € 750 € 850 € 750 € 850 € 950 €1 day / 1 jour 11/10 12/10 75015 PARIS 450 € 550 € AAMS WRITTEN EXAMINATION (for the AAMS delegates in 2nd cycle - October 13, 11.00 am/1.00 pm) 550 € MEMBERSHIP WOSAAM 1 YEAR (150 € for individual member - Free for Scientific Societies or Associations) 150 € SUBSCRIPTION JEAAM (Journal of European Anti-Aging Medicine) - 1 Year (4 issues) 100 €PAYMENT / Paiement des droits d’inscriptionPlease find enclosed the total payment of / Veuillez trouvez, ci-joint, mon règlement total de :Total : .......................... €Bank check in € to Euromedicom / Chèque en € à l’ordre d’Euromedicom Bank transfer in € to Euromedicom / Virement bancaire en € en faveur d’Euromedicom☛ In case of payment by bank transfer, please add 15 € to the total fees (bank charges) / En cas de paiement par virement bancaire, merci d’ajouter 15 € au montant total (frais bancaires)☛Please tick the day / Cochez le jourPaying bank: HSBCAddress: 10 bis ave Gabriel Peri - F-95100 ArgenteuilAccount holder: Euromedicom sarl Credit card / Carte de crédit : Visa Eurocard/Mastercard American Express Diners ClubCard number / N° de carte : Card holder’s name / Nom du porteur : ________________________________________________Expiry date / Date d’expiration}}Please tick the day(s)Please tick the day(s)Bank code: 30938Branch code: 00051Account number: 00106040002Key digits: 01Early registrationbefore / avant30 September <strong>2006</strong> 3 digits code / Cryptogramme : Late registration after / après30 September <strong>2006</strong>and on-site / et sur placeNo registration will be validated without certificate or proofAucune inscription ne sera validée sans l’envoi d’une attestationIBAN : FR 76 3093 8000 5100 1060 4000 201BIC - SWIFT : LUBPFRPPThe payment transfer form should clearly state the name(s) of the delegate(s) and the reference “<strong>EMAA</strong> <strong>2006</strong>”Précisez le nom du ou des congressiste(s) et la référence « <strong>EMAA</strong> <strong>2006</strong> » sur les documents bancairesSignature :CANCELLATION POLICY / ANNULATION• Before 30 September <strong>2006</strong>: refund -10% / Remboursement -10 %• Between 30 Sept. <strong>2006</strong> and 10 October <strong>2006</strong>: refund -30% / Remboursement -30 %• After 10 October <strong>2006</strong> : no refund / pas de remboursement I would like to receive .... train reduction coupons / Je souhaite recevoir ... coupons de réduction SNCF I would like to receive an official letter of invitation (Visa formalities) / Je souhaite recevoir une lettre officielle d’invitation pour l’obtention de VisaPlease fill 1 FORM PER PERSON and send to / Compléter 1 BULLETIN PAR PERSONNE et le renvoyer à :<strong>EuroMediCom</strong> - 29 boulevard de la République - 92250 La Garenne-Colombes - FranceTel : +33 (0)1 56 837 800 - Fax : +33 (0)1 56 837 805 - Email : world@euromedicom.comRegistration on line with secured credit card payment / Inscription en ligne avec paiement sécurisé www.euromedicom.com

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