Accommodation and Registration Form - IMMUNE-MEDIATED BRAIN INJURY AND REPAIR: MECHANISMS AND THERAPIES.

Please complete and return this form, together with your payment, to:
Secretariat
ENS SATELLITE SYMPOSIUM HAIFA
P.O. Box 50006, Tel-Aviv 61500, Israel
Tel: +972-3-5140004
Fax: +972-3-5140044, 514 0077
E- Mail: ktc@kenes.com

Identification
Please complete this section accurately; the information you provide will allow us to correspond with you efficiently, and will also be used on your delegate badge at the Congress.
Field marked in red are required.

Participant
Surname
First Name
Title
Mailing Address
No.
Street
Suite/Apt.
City
State/Province
Postal Code
Country
Telephone: (office hours) Country code/city code/number
Fax: Country code/city code/number
E-Mail:
Accompanying Persons List only those individuals registering for the Accompanying Persons' Program:
Surname
First Name
Title
Surname
First Name
Title
Surname
First Name
Title

Registration Fees
	Until April 20, 2000	After April 21, 2000
Full Participant	US$ 110.-	US$ 150.-
Student/Resident	US$ 90.-	US$ 120.-
Accompanying Person X	US$ 80.-	US$ 80.-
* With photocopy of valid proof of status.

Accommodation
Type of room required Single Double Other
First Choice
Second Choice
Check in date
Check out date
Total night(s)
*I will share my accommodation with

Tours
		Rate	No. of Seats
A Galilee Tour	June 16-17, 2000	Single US$ 195 Double US$336	Single Double

Airport Assistance

Arrival on: Airline: Flight No: Time:h.

Please arrange arrival transfer from the airport to Haifa at additional cost of US$ 45 per person

Departure on: Airline: Flight No: Time:h.

Please arrange departure transfer from Haifa to the airport at an additional cost of US$ 45 per person

Group Transportation

Please book seats on the group transfer on June 16, 2000 from Haifa to Jerusalem, at the cost of US$25 per person.

Payment Please indicate amount enclosed and ensure that your fully completed registration form is sent together with your payment:
Total Fees: US$ (registration fees + Hotel deposit)
Method of Payment Option 1: Credit Card -will be charged US$
Visa MasterCard Diners
Number
Expiration Date (month/year)
Name as shown on card: Surname
First Name
Signature (printed form only)	__________________________
Option 2 - Bank Transfer: - with your name and address indicated on the reverse. If payment is made for more than one person or by a 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 drafts payable to: ENS SATELLITE HAIFA and send them to Bank Leumi Le'Israel, Gan Hair Branch, Tel-Aviv, Israel, Account number 654-56165/61 Bank charges are the responsibility of the payee and should be paid at source in addition to the registration and accommodation fees. Option 3 - Payment by cheque, made payable to: ENS SATELLITE HAIFA Enclosed cheque number:______________________ Bank:______________________ Option 4 - Western Union Quick Pay Pay in cash in local currency with Western Union Quick Pay. Take your payment to the nearest Western Union location and complete the blue Quick Pay form with the following information: Full Name: Payments will not be processed without ones full name and address on the form Company name: KENES TOURS Locale/Code City: KENES, IK Account Number: ENS SATELLITE HAIFA Name/Department: REGISTRATION & ACCOMMODATION Western Union will send your payment to us electronically. For the western Union Location nearest to you, consult your local telephone directory.

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