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Registration Form

ASPHER ANNUAL CONFERENCE
September 11 - 14,
Centre for Training and Research in Public Health (CEFPAS)
Sicily (Italy)

PARTICIPANTS ARE STRONGLY ENCOURAGED TO REGISTER ON LINE AT: WWW.CEFPAS.IT/ASPHER

There have been some technical problems related to the Telecom Server therefore, if you have registered on line, please check if your registration status is OK by searching your name on the participants list. If it is not, kindly send an e-mail to arnone@cefpas.it or, alternatively, call Dr. Roberta Arnone (0039 0934 505381/505204). If you have not registered yet print this " version" of the registration form and send it by fax to 0039 0934 594310 or send it by e-mail to congressaspher@cefpas.it

DELEGATE

Family Name

Title

First Name

Sex (M/F)

Organisation

Position in Organisation

Address

City

Country

Tel

Country code

Area code

Number

Fax

E-mail

If further participants from your organisation wish to attend the conference, please complete an additional form.

REGISTRATION FEES
Early=Before 30/06/04(Incl) - Late=After 01/07/04(Incl)

ASPHER Member
Early Late
€ 300 € 350,00

Non ASPHERMember
Early Late
€ 350,00 € 400,00

-----------------------------------------------------

Students
Early Late
€ 75,00 € 125,00

° Student's Registration Fee doesn't include Gala Dinner
(Euro70,00) I wish to book Gala dinner

Payment at the time of the Registration

° Admission to all scientific sessions

° Conference documents (Program and Book of Abstracts)

° Certificate of participation

° Coffee breaks (11-12-13-14 September)

° Lunches (12-13 September)

° Opening evening buffet (11 September)

° Opening Ceremony (12 September)

° Gala dinner at Mussomeli's Castle (13 September - transfers included)

° Admission to all scientific sessions

° Conference documents (Program and Book of Abstracts)

° Certificate of participation

° Coffee breaks (11-12-13-14 September)

° Lunches (12-13 September)

° Opening evening buffet (11 September)

° Opening Ceremony (12 September)

ACCOMPANYING PERSONS

Number of accompanying persons

Family Name

Title

First Name

Sex (M/F)

Accompanying € 150,00

° Opening evening buffet (11 September)

° Opening Ceremony (12 September)

° City tour of Caltanissetta (13 September)

° Gala dinner at Mussomeli's Castle (13 September - transfers included)

ACCOMMODATION

All rates are inclusive of breakfast buffet, service charge and VAT.

Arrival Date

(ex.: dd/mm/yyyy)

Depature Date

(ex.: dd/mm/yyyy)

N. of nights

(ex.: 3))

Hotel Cefpas Residence (*)

Room

(Booking fees included)
(twin/triple room not available)

The full amount for the accommodation at CEFPAS must be paid for at the time of Registration.

Hotel San Michele (* * * *))

Booking and payment must be forwarded to Hotel San Michele - Via Fasci Siciliani Caltanissetta - Tel. + 39 0934 553750 - Fax +39 0934 598791 http://www.hotelsanmichelesicilia.it

SUNDAY TOUR - Visit to Agrigento (12 september 2004)

I wish to book (N. of seats) at Euro 60 per person

The above price includes bus, dinner and guide. The tour is subject to minimum numbers and availability.
The amount for the tour must be paid for at the Registration desk at Cefpas.

METHODS OF PAYMENT

Full payment of Registration fee, accommodation at CEFPAS (and, where applicable, social event) must accompany this form.

Please tick one box

Payment : Bank transfer or Credit card, details given below

Payment should be made in EURO in one of the following means:

- Delegate/speaker/student Registration fee Total €
- Accompanying persons Total €
- Accommodation at CEFPAS Total €
- Sunday tour Total €



° BANK TRANSFER
Bank code and Account N.: IBAN: IT10 R051 3216 7008 4157 0077 309
Swift Code:	B P V I I T 3 T
Bank name:	Banca Nuova Sportello di Tesoreria CEFPAS
Bank address:	Corso Umberto I°, 114-118 93100 Caltanissettaa
CEFPAS
ALL BANK FEES MUST BE PAID BY REMITTER AND FULL PAYMENT MUST ACCOMPANY THIS FORM

° BY CREDIT CARD (VISA) (+ 3% administration fees)

Please contact 0039-0934505204 - 0934505369

CANCELLATION TERMS AND CONDITIONS:
1) The Congress Secretariat must receive notification of all cancellations in writing.
2) Cancellations received on or before 30th of June 2004 will be subject to 10% cancellation fee.
3) Cancellations received after the 1st of July 2004 inclusive will be subject to a 50% cancellation fee.
4) No refunds after the 30th of July 2004
5) Note: Substitute participant from the same organisation will be accepted


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