Registration Form

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You may fill the form below and send it through this web site.
The form may also be sent by e-mail or fax to the secretariat at:
Secretariat
4th INTERNATIONAL CONFERENCE ON THE MEDICAL ASPECTS OF TELEMEDICINE
P.O.Box 50006, Tel-Aviv 61500 Israel
Tel: 972-3-5140000
Fax: 972-3-5175674 or 972-3-5140077
E-Mail: telemed99@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 January 15,1999	After January 15,1999
Participant	$380	$430
Pre- Conference Workshop A- B-	$60	$60 (per workshop)
Accompanying Person *	$150	$150
Farewell Dinner	$65	$65
Members of the ISFT will receive a US$ 50 reduction of the registration fees Please mark
Payment
Total Fees	$
Method of Payment
Check sent via airmail made patable to :4th INTERNATIONAL CONFERENCE ON THE MEDICAL ASPECTS OF TELEMEDICINE	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 : “4th INTERNATIONAL CONFERENCE ON THE MEDICAL ASPECTS OF TELEMEDICINE" and send them to Bank Leumi Le’Israel, Gan Hair Branch, Tel-Aviv, Israel, Account number 654/56115/76 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:Please write Name of Conference 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.
If you print this form and send it by fax or airmail please sign here _________

Cancellation policy:
Refund of Registration Fees will be made as follows:
Post-marked prior to January 15, 1999 - full refund less US$ 50 handling fee
Post-marked from January 16, 1999 - May 20, 1999 - 50% refund
Post-marked after May 20, 1999 - no refund

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