Please send the Registration Form by:■ eMail: l.adami@lswr.it■ Fax +39 02 93661586

Personal data

Family Name

First Name

Place and date of birth

Medical Specialty

VAT/Fiscal Code

Address

Personal Professional

Institution

Address

City

CAP/Zip Code

Country

Telephone

Fax

E-mail

Privacy Policy - Your personal data will be treated only by Edra S.p.A., in its electronic data bank and in full respect of the Privacy Code (Italian Law, D. Lgs. 30/06/2003 n. 196), in defense of personal data. The personal data treatment, whose we guarantee the complete privacy, will be done only for communication and medical scientific upgrade purposes. Your data will not be transmitted or spread abroad to others. At any time you will be allowed to require the cancellation or modification of them writing to the atten-tion of Edra S.p.A. (privacy@lswr.it)

I agree I do not agree

Date Signature

Registration FEES / Payment Form >>>

8th EUL AR COUR SEon Capillaroscopy in Rheumatic Diseases

September 13th-15th, 2018 • Genova, Italy

R E G I S T R A T I O N F O R M

REGISTRATION FEES (VAT included)

PACKAGE 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . € 1.300,00Includes: attendance to the scientific sessions, certificate of attendance, coffee breaks, lunches, dinner, Hotel accommodation at Congress Venue in single occupancy room 2 nights (IN Sept. 13th - OUT Sept. 15th, 2018).

PACKAGE 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . € 850,00Includes: attendance to the scientific sessions, certificate of attendance, coffee breaks, lunches.

● Please specify if you applied for Eular bursary also YES NO

HANDLING FEE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . € 50,00

TOTAL (PACKAGE + HANDLING FEE) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

● Extra-nightsGet into contact with Tower Genova Airport Hotel & Conference CenterVia Pionieri ed Aviatori d'Italia, 44 - Genova 16154 - Italy - Phone: +39 010 65491 - Fax +39 010 6549055eMail: annamaria.deiana@towergenova.comThe hotel will charge extra-nights.

PAYMENT BY

Bank transfer to: Edra S.p.A. - Cause “8th EULAR Capillaroscopy Course”. Please indicate the name of participant. Bank: UNICREDIT MILANO PIAZZALE Cadorna,15 IBAN CODE: IT43H0200801628000103618000 – BIC CODE: UNICRITM1228

VISA Eurocard/Mastercard Amex Expiration date CVV Code

nr. For €

Credit card holder’s name

Date Signature

Banks must be instructed to make payments in Euro “in full” to ensure no commission or bank charges are deducted. Please remember to send a copy of the bank receipt along with the Registration Form.

• Early registration it is advisable. Number of participants is limited.• Admission or non-admission will be communicated by email or fax within the September 3rd 2018. Registration with

payment will be required within July 30th 2018. • If the payment is not booked in our account within the mentioned timetable, the reservation for participation in the courses

cannot be guaranteed.

CANCELLATION AND REFUND

All refunds will be handled 4 to 6 weeks after the closing of the Course.• Cancellation received by July 30th 2018: 70% refund• Cancellation received after July 30th 2018: no refund• All cancellations must be in writing and faxed/emailed to the organization staff. If you are unable to attend, a substitute

delegate is welcome at no extra charge. Please be sure that he/she can present identification and a letter from the registered participant.

8th EUL AR COUR SEon Capillaroscopy in Rheumatic Diseases

R E G I S T R A T I O N F O R M

,

,

/

✗