EUROPEAN STRABISMOLOGICAL ASSOCIATION 25th MEETING

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Home Page

Letter From
The Chairman

Committees, Timetable
& Meeting Topics

Program

Call for Papers /
Submission of Abstracts

General Information

Travel and
Accommodation

Pre Meeting Tours

Post Meeting Tours

Accompanying Persons
Program

Registration Form

Accommodation Form

Download Abstract Form
(word 6/95 format)

REGISTRATION FORM

You may fill the form below in order to register for the congress.
You can also print the form and send it by fax to the secretariat at:
Secretariat
25th ESA Meeting
P.O.Box 50006, Tel Aviv 61500 Israel
Tel: +972-3-5140000
Fax: +972-3-5175674 or 972-3-5140077
E-Mail: strabismological@kenes.com

IDENTIFICATION
Please complete this section accurately; the information you provide will allow us to correspond with you efficiently, and it will also be used for your delegate badge at the Congress..
*Fields printed in red are required and must be filled

Participant
Surname:
First Name:
Title:
Department:
Institution:
No:
Street:
Suite/Apt.:
City :
State/Province:
Country:
Postal Code:
Telphone:
Fax:
E mail:
Mailing Address if Different From Above
No:
Street:
Suite/Apt.:
City :
State/Province:
Country:
Postal Code:
Accompanying Persons List only those individuals registering for the Accompanying Person's program
Surname
First Name
Title
Surname
First Name
Title
Surname
First Name
Title
Registration Fees Please check the appropriate box/es	Until June 30,1999	After July 1,1999
ESA members	$330	$380
None Members	$390	$440
Doctors in Training	$200	$230
Accompanying Person *	$150	$150
Payment
Total Fees	$
Method of Payment
Check sent via airmail made patable to :ESA 25th Meeting	Check Number:	Bank:
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 : “ESA 25th Meeting" and send them to Bank Leumi Le’Israel, Gan Hair Branch, Tel-Aviv, Israel, Account number 654-56127/69 Patam. Bank charges are the responsibility of the payee and should be paid at source in addition to the registration fees.
Credit Card	Visa : Mastercard: Dinners:
Card Number
Expiration date
Names as shown on credit card
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: ESA 25th Meeting Name/Department:Registration Western Union will send your payment to us electronically. For the Western Union Location nearest to you, consult your local telephone directory.
If you print this form and send it by fax or airmail please sign here _________

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