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
If on line registartion is not possible please complete this form(print in BLOCK letters in BLACK)and return together with your payment to: CEFPAS - Via Mulè 1 - 93100 Caltanissetta - Italy
Tel 0039 (0)934 505204 - Fax 0039 (0)934 594310
e-mail 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
Non ASPHERMember
Students

° Student's Registration Fee doesn't include Gala Dinner
(Euro70,00)

I wish to book Gala dinner

Payment at the time of the Registration

Early                       Late
 
€ 300,00               € 350,00
€ 350,00               € 400,00
€ 75,00                 € 125,00
 
 
 
 
 
 
 

ACCOMPANYING PERSONS
   
  Number of accompanying persons  
  Family Name  
  Title  
  First Name  
  Sex (M/F)  
     
  Accompanying € 150,00
     

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 (* * * *)  
  Room  

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

     
 - Delegate/speaker/student Registration fee                Total €  _____________
 - Accompanying persons                                                Total € _____________
 - Accommodation at CEFPAS                                         Total € _____________
 - Sunday tour                                                               Total € _____________
        OVERALL TOTAL €  _____________
Payment should be made in EURO in one of the following means:
° 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 Caltanissetta
Account holder:  

CEFPAS
ALL BANK FEES MUST BE PAID BY REMITTER AND FULL PAYMENT MUST ACCOMPANY THIS FORM
     
° BY CREDIT CARD (VISA)    (+ 3% administration fees)
  Cardholder's Name  
  Address  
  Card Type  
  Card Number  
  Expiry Date _______ / __________ (ex.: mm/yyyy)
  Cardholder's Signature  
 
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