REGISTRATION FORM

Number of training: 11940701394
R E G I S T R AT I O N F O R M
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REGISTRATION IS INDIVIDUAL, NAME SPECIFIC AND NON-TRANSFERABLE
TO RETURN TO ADDRESS BELOW IN AN ENVELOPE WINDOW
CHANNELOPATHY MEETING
PARIS
June 15-17
2016
RAPHAËL GASSIN
RELATIONS MÉDICALES - C152
34, Grande Rue Charles de Gaulle
94130 NOGENT-SUR-MARNE
FRANCE
>> June 15-17, 2016 <<
ICM, Institut du Cerveau et de la Moelle épinière
Hôpital Pitié Salpêtrière
47 / 83, boulevard de l’Hôpital
75013 PARIS, France
Identity:
Mr
Ms
Title:
Dr
Pr
First name*: .................................................................................. Family name*: .............................................................................................
Position: ......................................................................................... Specialty*: .................................................................................................
Address:
Private
Professional
Institution affiliation*: .............................................................................................
............................................................................................................................................................................................................................
Country code:................................................City: .............................................................................................................................................
State: ................................................................
Email*: .............................................................. @ ........................................................
Mobile phone*: ...........................................................Telephone: ........................................................Fax:......................................................
* Required fields
REGISTRATION FEES
NB : Conference registration implies that you approve all the terms you read below.
Due to the size limitation of the auditorium, only the first 180 registrations will be accepted.
STATUS
PRICES
PRICES
Academic researchers or non-profit organisations:
o 360 € TTC
o 420 € TTC
Early-stage researchers (≤35 years):
o 180 € TTC
o 240 € TTC
Industry representatives and profit organisations:
o 510 € TTC
o 600 € TTC
REGISTRATION
1
Registration fees
(including taxes)
1
Registration fee includes: The access to the conference rooms and to the other events of the meeting, lunches and coffee breaks for 3 days
GALA DINNER
The gala dinner will take place on the Bateau Mouche
« Le Zouave « The following participation includes a cruise and the dinner.
Only the first 100 gala registrations will be processed.
Academic researchers or non-profit organisations:
o 50 € inc. VAT
Early-stage researchers (≤35 years):
o 30 € inc. VAT
METHOD OF PAYMENT: please return form and payment to Relations Médicales
Total to be paid:
Credit card:
CB
VISA
AMERICAN EXPRESS
MASTER CARD
Name on credit card: ............................................................................. Expire date: __ __ / __ __
Carte number: /__ / __ / __ /__ / __ / __ /__ / __ / __ /__ / __ / __ /__ / __ / __ /__ /
Cryptogram (3 or 4 last digit on verso): / __ / __ / __ /__
For bank transfert: Code IBAN : FR76 30003 03924 00020829259 76 - Code BIC : SOGEFRPP
Bank: SOCIÉTÉ GÉNÉRALE - 7, Bd de Strasbourg - 94130 Nogent-sur-Marne - France
i
INFORMATION & REGISTRATION: Relations Médicales - Raphaël GASSIN - Tél. +33 (0)9 61 22 30 44
Fax: +33 (0)1 48 76 03 62 - E-mail: [email protected]
www.infocongres.com
............................. €
Date and signature
GENERAL CONDITIONS FOR REGISTRATION
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> events > training > congresses
n Registration procedures:
> On-line : www.infocongres.com
> By completing the registration form available on www.infocongres.com
> No entries will be accepted by any other means.
> Young investigator: please provide an identity document with the registration form
n Validation of the registration: Only registration accompanied by payment or officially confirmed “covering” is accepted ; the postmark
will be taken as proof of submission.
n Nominative registration: Registration is individual, name specific and non-transferable. Under no circumstances shall this registration be
exchanged or transferred.
A name badge is issued to the participant on arrival at the event, upon presentation of the acknowledgement of registration and ID.
Any name change is considered as a cancellation and a new registration, invoiced according to the applicable rates.
n Confirmation of the registration: Registration confirmation of participant is only made via E-mail for each registration form.
Please ensure that your E-mail address is duly mentioned and readable in order to receive the acknowledgement of your registration.
Any incomplete application will not be processed and will not be taken into consideration after the closing date for registration.
n On-site registrations: In case of on-site registration, fee will be increased by 20 euros. Any unpaid registration before the Convention will
be subject to the same fare.
n Closing date for registration: Closing date for registration will be communicated via the website www.infocongres.com
Nevertheless, once meeting capacity has been reached, registration will be no more possible. All registrations received after the closing
date will be refused (the postmark will be used as proof of submission).
n Non-validated registration: All registrations received after the closing date will not be returned to the sender; the check will be destroyed
by us.
n Covering: All registration processed by training agencies, a company, a pharmaceutical laboratory or any other payment issued by any
entity other than the participant will be considered as covering.
> Training agency: An agreement of covering stating the beneficiaries will be sent to the Organizational Committee in duplicate.
> In the event of non-receipt of the document duly completed and signed in the allocated timeframe, the registration of the
beneficiary shall be required at “On-site registrations” fare.
> Invoice : Issued on tax-free basis, increased by the rate of VAT prevailing at the time.
n Cancellation: Any request must be made in writing (fax, mail or e-mail:[email protected]) and sent to company Relations
Médicales. Any reimbursement will be processed after the meeting, less applicable administrative fees (30 euros).
n Administrative fees: 30 euros will be charged per amendment of registration.
n Reimbursement: Reimbursements will be made after 30 calendar days from the event. The Organizational Committee will not be held
responsible of disturbances, strikes or any external events that might prevent the attendance of participants and/or lead to the annulment
of the meeting.
n Registration fees: Only the date on which payment was issued (the postmark will be taken as proof of submission) determines
Registration fees. Any irregular payments will lead to the cancellation of the registration.
n Payment of registration: All payments will be made following a valid registration (see registration procedures).
For all payments made by credit card or check, participants have up to 15 calendar days to submit the payment. In the event of non-receipt
within the allocated timeframe, registrations will be automatically cancelled.
n Bank transfer: This must be clearly identified indicating name and last name of the participant. Any charges of the transfer are entirely
chargeable to the participant. Any charges supported by The Organizational Committee will be re-billed and added to the administrative
fees.
n Failed credit card transaction: Participants must ensure with the bank that the transaction will be accepted. In the event that transaction
fails, from the 3rd attempt, bank charges equal to 5% of registration fees will be charged to the participant.
Les informations recueillies font l'objet d'un traitement informatique destiné à la gestion de suivi de clientèle.
Le destinataire des données est RELATIONS MÉDICALES.
Conformément à la loi « informatique et libertés » du 6 janvier 1978 modifiée en 2004, vous bénéficiez d'un droit d'accès et de rectification
aux informations qui vous concernent, que vous pouvez exercer en vous adressant à [email protected]
Vous pouvez également, pour des motifs légitimes, vous opposer au traitement des données vous concernant.
Relations Médicales est enregistré à la CNIL depuis le 26 août 2005 sous le N° 111 57 38
Relations Médicales - Raphaël GASSIN SAS I 34 Grande Rue Charles De Gaulle - 94130 Nogent-sur-Marne
Tel.: +33 (0)9 61 22 30 44 I Fax: + 33 (0)1 48 76 03 62 I E-mail : [email protected]
SIRET: 478 007 545 00013 I R.C.S. CRÉTEIL 478 007 545 I N° TVA Intra. FR 614 780 07 545