Home
Introduction
Program
Information
Registration
October 12 - 13, 2006 University Medical Center Groningen
Groningen, The Netherlands
Arrhythmias from Neonate to Adult - Part II
I would like to register for:
the congress :
Arrhythmias: from Neonate to Adult, part II
(registration fee € 150,00)
Yes, I will also attend the social event on Thursday evening, October 12. (€ 75,00 )
No, I am not able to attend the social event on Thursday evening
Participant Information
Family Name
Prof.
Dr.
Mr.
Mrs.
Ms.
First Name
Gender
Male
Female
Affiliation / Profession
Pediatric cardiologist
Cardiologist
Pediatrician
Cardiothoracic surgeon
other
Mailing Address
Home
Business
Street Address
Postal Code / ZIP
City
Country
E-mail
Tel
Fax
Payment in Euro – Please indicate method of payment
For Dutch participants
Per authorization
(will be enclosed in confirmation letter)
Per bank transfer
(details will be enclosed in confirmation letter)
For international participants
Bank transfer
(details will be enclosed in confirmation letter)
Cheque
(details will be enclosed in confirmation letter)
Please fill out all fields