Registration form - EAZA - European Association of Zoos and Aquaria

Document Sample
Registration form - EAZA - European Association of Zoos and Aquaria Powered By Docstoc
					*To complete this form in Microsoft Word use the Tab key to move from field to field.

                                         Conzoolting & EAZA Nutrition Group
                th
               6 European Zoo Nutrition Conference, Barcelona: 28-31st January 2010
                                     REGISTRATION FORM
Participant Details
Name:                                           Affiliation:
Email:                                          Phone:
Postal Address:

Partner Name (if applicable):

Attendance Social Programme (please tick boxes):

Visit Barcelona Zoo on Thursday 28 January                                                  Yes                No
Ice Breaker on Thursday 28 January                             €20                          Yes                No
Dinner on Saturday 30 January                                  €45                          Yes                No
                                   Total to be paid by participant:

Registration Fees:                        Before 15 NOV 2009                            After 15 NOV 2009             Amount
Fee Full Conference                           € 145                                 € 185                             €
Student Conference Fee                        € 135                                 € 160                             €
Single Day Fee                                   € 80 (indicate which date:          )                                €
                 Attendance social programme (if partner attends, please include costs)                               €
                        5% Credit Card Fee (please add if paying by Credit Card)                                      €
                                                                                         TOTAL                        €


Please indicate any dietary requirements:

Indicate your method of payment:

         I will pay with my credit card (please note that 5% credit card fee should be added to costs)
         Please complete the details below:

Card type:                   Visa                         Card Number:
                             Mastercard                   Expiry Date:
                             American Express             CCV Number:                    (3 digits on back of card)

Cardholder Name:                                Signature:          ______________________

         I will pay by direct bank transfer

         Account number:           83.99.64.897
         Bank:                     Fortis Bank, Amsterdam
         BIC:                      FTSB-NL-2R
         IBAN:                     NL74 FTSB 0839 9648 97
         EAZA Executive Office, PO Box 20164, 1000 HD Amsterdam, The Netherlands
         REF: Nutr2010/[PARTICIPANT NAME]

Indicate if you will (please tick box):

Submit a poster/presentation abstract (use Presentation form)                               Yes                No
Submit a Diet Change Case Study (use Diet Change form)                                      Yes                No
Bring a donation for the silent auction                                                     Yes                No

Please complete this form and return it by email or fax to:
EAZA Executive Office Email: info@eaza.net              Fax: +31 20 520 0752

				
DOCUMENT INFO
Shared By:
Categories:
Stats:
views:11
posted:3/3/2010
language:English
pages:1