Lebanese Society of Neurology by alicejenny

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									                   Lebanese Society of Neurology
                 3rd International Congress of the LSN
          Grand Hills Hotel & Resort, Broumana – September 22-25, 2011

                  Application For Reduced or Exempt Dues

Please Print in BLOCK LETTERS and Fax or E-Mail to LSN Congress Office
Tel/Fax + 961 1 429 898 – lsncongress@gmail.com – lsneurology@hotmail.com

(Please TYPE or Type in BLOCK LETTERS)

Name……………………………………………………... First Name……………….…………………

Title
Address………………………………………………………………………
……………………………………………………………………………..…I
Insitution………………………………………Country……………………..
Fax (Country Code/City Code/Number) ………………………………….....
Telephone (Country Code/ City Code/ Number)………………………….....




I will be attending the following Teaching Course on Thursday Sept. 22:
       A - Teaching courses (Kindly select one course)
          Epilepsy                 Dementia           Stroke
          Botulinum Toxin          ENMG

Course Fee…………………………………………………………
Course Fee for Resident/Fellow ………………………………… 25 $
(Can be independent from Registration to Congress)

        B- Registration Fees (Scientific Sessions/Lunches/Breaks/Bag/Badge)

                                  – Supporting Doc. To be attached …………………….    120 $
                                                                               310 $
Can Contribute by the following Amount
  A- Teaching Course                   US$.........
  B- Registration                      US$.........
  TOTAL                                US$.........

BANK TRANSFER – With your name and address indicated on this form. If payment is
made for more than one person or by company please make sure all names are indicated
and send fully completed Registration and Accommodation Forms together with a copy
of the bank transfer. Please make payments to:
               Société Libanaise de Neurologie
               A/C # 200. 0710126. 007
               Banque Byblos SAL – Branche Sassine – Liban
               Swift: BYBALBBX

Bank Charges are the responsibility of the participant and should be paid at source
in addition to the registration and accommodation fees.

Write a few sentences to underline objectively the cause(s) of the exempt dues
demand:……………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
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Date…………………………….. Signature …………….…………………

Kindly note that 20% of the above mentioned total amount will not be refunded as the result of cancellation
received before Sept 5th, 2011. Cancellation after Sept. 5nd, 2011 will not be refunded.


                            Form to be sent to the LSN Office
                     LSNeurology@hotmail.com/ lsneuro@lsneuro.org
                                    Fax/ 01 429898 /
                             Telephone/ 71 573937/ 71 940943

								
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