N.B.

I. Information marked with a * is required!
You can click the grey terms in case you are not sure which information to give.
Please read our application guidelines and abstract guidelines before filling in the form below.

II. Everything should be written in latin symbols. DO NOT use any phonetical symbols that are unique in Your native alphabet when filling the form. If otherwise we do not take any responsibility when printed.

 

Your Title* (Dr., Mrs., Mr., ...) :
Your First Name (+ Optional Middlename)*:
Your Last Name*:
Your Date of Birth*: (Year/Month/Day, e.g. 71/12/28 or 1971/12/28)
Your Passport Number*:
Your Passport Country*:
Date of Expiry*:
Your E-mail Address*:
Your Mobile Phone Number:
Your Fax Number:
Your Post Address*:
Your Post Address (continue):
Country*:	* Please Select Country * Albania Armenia Austria Azerbaijan Belarus Belgium Bosnia-Herzegovina Bulgaria Croatia Czech Republic Denmark Estonia Finland France Georgia Germany Greece Hungary Iceland Ireland Israel Italy Latvia Lithuania Luxembourg Macedonia Malta Moldova The Netherlands Norway Poland Portugal Romania Russia Slovakia Slovenia Spain Sweden Switzerland Turkey Ukraine United Kingdom Yugoslavia Other
If Other:

University

Your University*:
Your Department:

Subject of Your Curriculum*:

Medicine
Dentistry
Pharmacy
Other (Please Specify):
Do you want a post congress tour?	Yes       No
Do you want us to arrange your accomodation?	Yes       No