Printable registration form _PDF_ - EORTC

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					                               3 rd International NCI-EORTC
                            Meeting on Cancer Molecular Markers
                                 From Discovery to Clinical Practice
                                          April 18-20, 2004

                                       Registration Form
                               Registration deadline: March 1 st, 2004



                     PLEASE FILL OUT USING UPPER CASE LETTERS ONLY


Salutation (Mr./Mrs./Ms./Dr.): ______________      Degree (MD/PhD/MS/RN): ____________________

First Name:      _______________________________________________________________________

Last Name:       _______________________________________________________________________

Job Title:       _______________________________________________________________________

Affiliation:     _______________________________________________________________________

Department:      _______________________________________________________________________

Mailing Address:       _________________________________________________________________

                       _________________________________________________________________

City:          _______________________________ State/Zip: _______________________________

Country:       _________________________________________________________________________

Tel: ___________________________________           Fax :      __________________________________

E-mail: ___________________________________________________________________________
REGISTRATION FEES

Registration Fee: 450.00 EUR (credit card and bank transfers accepted only in EUR only)
Covers registration, abstract booklet, cocktail on Sunday evening and lunches.

Cancellations prior to March 1st, 2004, will be at no charge. Cancellations received between March 1st
and April 1 st, 2004, will be assessed a fee of 100.00 Euros. No reimbursements will be made for
cancellations received after April 1st, 2004.

       I plan to attend the dinner on Monday 19 (50.00 EUR)


       I plan to pay the registration fee by Credit Card (MasterCard or Visa accepted only)

Credit Card Holder:    ___________________________________              Master Card           Visa Card

Credit Card Number: ________________________ Expiry Date: ____________________________

Total Amount to Charge: ______________________ Signature:           ____________________________


       I plan to pay the registration fee by bank transfer
       Please note that bank fees and exchange rates are to be borne by the participant
       FORTIS BANK
       Av. de l’Astronomie 14
       1210 Brussels, BELGIUM
       Account Name :       EORTC Molecular Markers
       Account Number :     001 - 4055620 – 29
       BIC / Swift code:    GEBABEBB36A
       IBAN:                BE26 0014 0556 2029
       Please clearly mention your NAME and your AFFILIATION when doing the transfer


Abstract Submission:

       Yes, I plan to submit an abstract for this meeting.

       No, I do not plan to submit an abstract for this meeting

               Please complete this form and fax it no later than March 1st, 2004 to:
                                         Ms Valerie Steele
                                         NCI Liaison Office
                                       Av. E. Mounier 83/10
                                      1200 Brussels, Belgium
                           Tel : (32 2) 772.22.17; Fax: (32 2) 770.47.54
                                       E-mail: ncilo@eortc.be

				
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