Secretariat:
THE INTERNATIONAL SYMPOSIUM AND COURSE ON BURNS AND FIRE DISASTER MANAGEMENT
P.O.Box 50006, Tel-Aviv 61500 Israel
Tel: 972-3-5140000
Fax: 972-3-5175674 or 972-3-5140077
E-Mail: medburn2000@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
Please mark the appropriate box(s) 
Until
December 15, 1999		 After
December 16, 1999
MBC Members US$ 340.- US$ 420.-
MBC Non-Members US$ 400.- US$ 480.-
Students US$ 240.- US$ 280.-
Accompanying Person X US$ 120.- US$ 120.-
Payment
Please indicate amount enclosed and ensure that your fully completed registration form is sent together with your payment:
Total Fees: US$
Method of Payment
Option 1: Credit Card -will be charged US$ 
Visa  MasterCard  Eurocard  Diners  American Express
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 forms together with a copy of the bank transfer. Please make drafts payable to : MedBurn 2000 and send them to Bank Leumi Le'Israel, Gan Hair Branch, Tel-Aviv, Israel, Account number 654-56151/72 Patam. Bank charges are the responsibility of the payee and should be paid at source in addition to the registration fees.
Option 3 - Payment by cheque, made payable to:MedBurn 2000
Enclosed cheque number:______________________ Bank:______________________
Please include fully completed registration form.
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:
Company name: Kenes Tours
Locale/Code City: KENES, IK
Account Number: Please write Name of Congress
Name/Department: Please write the word "Registration"
Western Union will send your payment to us electronically. For the western Union Location nearest to you, consult your local telephone directory.
Cancellation Policy
Refund of Registration Fees will be made as follows:
Postmarked before December 15, 1999 - 100% refund (minus US $40 handling fee)
Postmarked from December 15, 1999 - 50% refund
No refund on cancellations sent after January 10, 2000.
 

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