CONGRESS REGISTRATION FORM A

Please print this form, fill it out and return it to:

FIP Congresses & Conferences
PO Box 84200
2508 AE The Hague, The Netherlands
Fax: +31 70 302 1998 

Barcelona

Family name:..................................................... Given name:.................................. Title:.................
Full mailing address: ........................................................................................................................
.......................................................................................................................................................
Country:..........................................................................................................................................
Telephone:................................Telefax:................................Email address:.....................................
Date of birth: ..................................................................................................................................

Accompanying Person(s)
Family name:.......................................................... Given name:......................................................
Family name:.......................................................... Given name:.......................................................

Main language:[ ]English [ ]French [ ]German [ ]Spanish

Please indicate in which Pharmaceutical discipline you are active:

[ ]Hospital Pharmacy [ ]Military and Emergency Pharmacy [ ]Medicinal and Aromatic Plants[ ]Pharmacy Information
[ ]Community Pharmacy [ ]Industrial Pharmacy[ ] Clinical Biology[ ]Academic Pharmacy
[ ]Official Laboratories and Medicines Control Services[ ]Administrative Pharmacy

Registration fees are including 16% VAT which is compulsory in Spain .

    NLG Number of persons TOTAL NGL
  until May 1, 1999 930 1 ____________
[ ] FIP Member May 1 - August 1 1100 1 ____________
  onsite 1740 1 ____________
  until May 1, 1999 1390 1 ____________
[ ]  Non-Member May 1 - August 1 1570 1 ____________
  onsite 1740 1 ____________
  until May 1, 1999 350 1 ____________
[ ] Student/Recent graduate
(up to five years after graduation)
May 1 - August 1 400 1 ____________
(N.B. Please make sure that a document proving your status of Student/ Recent Graduate is included) onsite 470 1 ____________
[ ]Accompanying Persons   400   ____________
[ ]Symposia Pharmaceutical Care

Community Pharmacists Section Member [ ]

Non-Section Member [ ]

 

210

255

 

____________

____________

[ ] Gala Dinner   175   ____________
[ ] Yes, I would like to become a FIP Foundation Supporter (min. 25 NLG)       ____________
      TOTAL NLG  

FIP Membership number:............................................................................................

Please indicate clearly your membership number, otherwise you will be charged the fee for non-members. Your membership fee must be paid before May 1, 1999, otherwise you will be registered as a non-member.

Non-members who tick the appropriate box and sign will become an individual member of FIP free of charge for one year, from January 1, 2000.
[ ]
Yes, I would like to become a FIP member
[ ]
This is the first time that I will attend a FIP Congress. Signature: ..............................................................................................................................................
[ ]I would like to attend the Young Pharmacists Group reception Date: ..............................................................................................................................................

Payment (your registration is not valid until payment has been received; please make sure to always complete the payment details)

Payment should be made in Dutch Guilders (NLG) to FIP Congresses & Conferences. Please make sure to clearly indicate your name and FIP 99 Barcelona.

[ ] Bankers Cheque (personal or company cheques cannot be accepted)
[ ]
Eurocard/Mastercard [ ] Diners Club
[ ]
American Express [ ] Visa

Charge my card no.:..................................................................................................................................
with expiry date:................................................................................................................
Cardholders name in blockletters......................................................................................
Date: ............................/.........................../...........................
Cardholder signature .............................................................

Bank transfers can only be accepted after a special request in writing to FIP Congresses & Conferences, who will provide you with bank details and an invoice number, to make sure that your payment is correctly allocated.

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