REGISTRATION HOTEL RESERVATION FORM - EuroMediCom

AMWC - Anti-Aging Medicine World Congress 2013MONACO • April 4 - 5 - 6, 2013REGISTRATION FORM - TO BE SENT BY FAX TO +33 (0)1 56 837 805 (from America dial 011 33 1 56 837 805)ONLINE SECURED REGISTRATION ON: WWW.AMWC-CONGRESS.COMOnce your credit card debited we will destroy your payment details - Please do not send your registration scanned by email but only by fax.Family ____________________________________________________________________________________________________________________________NameUse capital letters when completing this formFirst ____________________________________________________________________________________________________________________________NameMedical ____________________________________________________________________________________________________________________________Specialty (obligatory field)Clinic ____________________________________________________________________________________________________________________________/ CompanyAddress ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Zip code City CountryPhone ______________________________________________________FaxMandatory ___________________________________________________________________E-mail:Your confirmation & invoice will be sent by e-mail - Please write as CLEARLY as possibleREGISTRATION FORMRegistration fees include: access to chosen sessions, workshops and commercial exhibit, coffee breaks, certificateof attendance, congress bag and conference documents.GALA DINNER- GALA DINNER «FOREVER YOUNG» / Saturday April 6 th at the Sporting-club of Monaco 200€Limited Seats! Gala x .......... person(s) = ................ €2-YEAR FREE WOSIAM (World Society of Interdisciplinary Anti-Aging Medicine) & World MediSpa Association MEMBERSHIP offered with this registration (for MDs only): Advantages as member will startafter this registration. If you do NOT wish to become a WOSIAM Delegate, please tick here www.wosiam.orgPAYMENT Bank check in Euros enclosed, payable to AMWCTOTAL TO BE PAID: ...................................................€ Bank transfer in Euros to AMWC - ADD 15 € for bank charges!!! VERY IMPORTANT: For administrative treatment purpose, BANK TRANSFER MUST BE MADE AT LEAST 10 DAYS PRIOR TO THE CONGRESS. Passed this date, the registrant may haveto pay on site his registration and will be eventually refunded after the congress. Administrative process may take up to 30 days to identify the transfer and proceed to the refund,after the event. OBLIGATORY: Do mention the registrant’s name + AMWC 2013 reference on all the bank documents.Paying bank: MON SDC MONACOAddress: Place des Moulins - 98000 MonacoAccount holder: AMWC MonacoBank code: 30002Branch code: 03214Account number: 0000060591DKey digits: 75IBAN: MC03 3000 2032 1400 0006 0591 D75BIC - SWIFT: CRLYMCM1Credit Card: Visa Eurocard / Mastercard American Express Diners Signature:Credit card number: ___________ ___________ ___________ ___________Cardholder’s name: __________________________________________________Expiry date: ______ / ______ 3-digit code (obligatory): _____________4-digit code (AMEX)Cancellation policy: • +30 days before: Total refund -50 € • Between 30 and 15 days: Refund -30 % • -15 days before: No refund.Cancellation will be processed after written demand and one month after the CongressPlease fill one form per registrant and send it (or copy) to: 2, rue de Lisbonne - 75008 Paris - FranceTel: + 33 (0)1 56 83 78 00 - Fax: +33 (0)1 56 837 805 - E-mail: amwc@euromedicom.com . registration@euromedicom.comON-LINE REGISTRATION: WWW.EUROMEDICOM.COM (Secured Payment)Once your credit card debited we will destroy your payment details - Please do not send your registration scanned by email but only by fax.After01/03/2013& on-sitePASS 1 : AMWC - 3 DAYS (April 4 th - April 5 th - April 6 th )Includes: All AMWC sessions (aesthetic dermatology, anti-aging medicine, FAT and cosmetic gynecology symposium, workshops & visit of the exhibition – coffee breaks included)- DELEGATE RATE 650€- MEMBER OF SCIENTIFIC SOCIETY RATE* Certification required 590€- STUDENT, NURSE, PHYSIOTHERAPIST, ASSISTANT RATE* Certification required 550€PASS 2 : PRE-CONGRESS AME - AESTHETIC MASTER CLASS FOR EXPERTS - 1 DAY (Wednesday April 3 rd )Includes: Pre-congress Aesthetic Master Class for Experts (AME) – coffee breaks and lunch (April 3 rd ) includedWorkshop for advanced experts where the participants will simultaneously see live localized injections made on a patient and the actual placement of a corresponding colored solutionunder the dissected cadaver skin. Limited seats!- DELEGATE RATE 1050 €PASS 3 : AMWC FULL PASS - 4 DAYS (April 3 rd - April 4 th - April 5 th - April 6 th )Includes: All AMWC sessions (aesthetic dermatology, anti-aging medicine, FAT and cosmetic gynecology symposium, workshops & visit of the exhibition – coffee breaks, and 3 rd April lunch included)+ Pre-congress Aesthetic Master Class for Experts (Wednesday April 3 rd )- DELEGATE RATE 1390€PASS 4 : AMWC EXHIBIT & WORKSHOPS ONLY - 3 DAYS (April 4 th - April 5 th - April 6 th )Includes: All companies’ workshops & visit of the exhibition - Unique rate for all participants (delegate, member, student, etc. – coffee breaks included)- VISITOR PASS 320€PASS 5: AMWC VIP PLATINUM PASS - 4 DAYS (April 3 rd - April 4 th - April 5 th - April 6 th )Includes: All AMWC sessions (aesthetic dermatology, anti-aging medicine, FAT and cosmetic gynecology symposium, workshops & visit of the exhibition – coffee breaks included).+ Pre-congress Aesthetic Master Class for Experts (Wednesday April 3 rd )+ VIP Services:- VIP «Fast Track» counter (registration, badge & congress material delivery)- Private Lounge access for 2 persons (permanent refreshment service in a sea-view room)- DELEGATE RATE 1490€