3rd International Congress on Coronary Artery Disease -Registration Form

Posters Sessions:

General
Information

Pre and Post Congress Tours

Registered Accompanying Persons Program

Accommodation

Accommodation and Tour Form

Registration Form

REGISTRATION FORM

Please complete and send the form or return, together with your payment to:
Secretariat
3rd International Congress on Coronary Artery Disease
PO Box 50006, Tel-Aviv 61500, Israel
Tel: +972 3 514 0000, Fax: +972 3 517 5674 / 514 0077
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.
(Please TYPE or PRINT IN BLOCK LETTERS)

Field marked in red are required.

Participant
Family Name
First Name
Middle Initial(s)
Title
Department
Institution
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)
	before August 10, 2000	after August 10, 2000
Participant	US$ 540.-	US$ 620.-
Nurse, Technician, Trainee *	US$ 320.-	US$ 390.-
Student **	US$ 220.-	US$ 270.-
Accompanying Person X	US$ 160.-	US$ 190.-
Farewell Dinner (Optional) US$ 70.- per person x
letter of verification required; *valid student card required

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 - Payments will be charged in US$
Visa MasterCard Diners American Express
Number
Expiration Date (month/year)
Name as shown on card: Surname
First Name
Signature (printed form only)	__________________________
Date (day/month/year)(printed form only)_________________________ For payment by Visa, please indicate home address if other than mailing
No.
Street
Suite/Apt.
City
State/Province
Country
Postal Code
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 return fully completed registration forms together with a copy of the bank transfer to the Secretariat. Please make drafts payable to: "3rd International Congress on Coronary Artery Disease" and send to: Bank Leumi Le'Israel, Gan Ha'ir Branch, Tel-Aviv, Israel, Account Number PATAM 654-56143/71. Bank charges are the responsibility of the payee and should be paid at source in addition to the registration fees. Option 3 - Cheque made payable to: 3rd International Congress on Coronary Artery Disease Enclosed cheque number:______________________ Bank:______________________ Please include fully completed registration form. Cancellation Policy Refund of Registration Fees will be made as follows: Post-marked prior to August 10, 2000 - refund less 25%. After this date, no refund can be made.

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