online registration 7th seminarBy test.drug-addiction / April 12, 2022 REGISTRATION FORM 7TH SEMINAR OF THE EUROPEAN SOCIETY OF CONTRACEPTION Budapest, Hungary 12-13 September 2003 Identification part (*obligatory fields) *Family name: *First name: *Title: *select your title*Prof.Dr.Dr.other *Title for correspondence: *select your title*MrsMsMr Institute: Department: *Street/Number: *Zip code: *City: *Country: Tel: Fax: E-mail: The above identification details might be used for future mailings. Please place a tick in the box if you do NOT wish your name and address to be included in the following kind of mailings: Not ESC-related activities Company related information Registration part (*obligatory fields) *I am a member of the European Society of Contraception (ESC): “please select”yesnot yet Hungarian participants *I register for the Seminar as: please selectESC member (paid-up) free of chargenurse or student**and pay 15 euro for registrationother and pay 30 euro for registrationnew ESC-member and pay 60 euro **For students: written evidence of status must be provided by an employer’s statement or copy of certificate. *I pay as follows: please select your method of paymentat arrival in Hungarian Forintsby credit card (euro/master/visacard)bankers draftbank transfer Participants from other countries *I register for the Seminar as: please selectESC member (paid-up) free of chargenon ESC-member and pay 60 euro *I pay as follows: please select your method of paymentby credit card (euro/master/visacard)bankers draftbank transfer In case of creditcard payment (eurocard/mastercard/visacard only) fill out next details: (if you don’t like to send your creditcardnumber through internet please print out the pdf registration file and send it to the ESC Central Office by mail or fax) You are allowed to charge my select your type of cardEurocard/MastercardVisa card Card number: Exp.date: Name of cardholder: I am willing to send my signature in writing to the ESC Central Office if requested by my creditcard company: selectyesno In that case you will be informed through the ESC Central Office. Note (1) : after submitting this registration form you receive a confirmation of the registration with payment details to print out for your administration! Note (2) : You can attend the workshops of your choice by simply stating your preferences on arrival. However, there will be limited spaces in each workshop so please book up on arrival!