9th FIAPAC Conference: Seville 2010

Please complete your personal details (*Required fields)

Title:

First name *:

Surname *:

Profession *:

Organisation:

Address *:

City *:

Postal Code *:

Country *:

Telephone:

Fax:

E-Mail *:

Please tick your preferred Membership

Regular Membership €50 Support Membership €100

Please tick your applicable registration fee for the 9th FIAPAC Conference: Seville 2010

Members €250 Members, non-Doctors €200
Non-Members €300 Non-Members, non-Doctors €250

- An extra € 80 will be charged for registrations after September 15, 2010
- Service charge for Credit Card payment: € 2.50

Please tick for the Gala dinner & Flamenco show on Friday night October 22

Gala dinner & Flamenco show €55

Please select your preferred method of payment

Due to extra costs for credit card transactions, we would highly appreciate if you choose to pay by (electronic) bank transfer -free of charge within the EU –

Payment by Bank Transfer (ABN/AMRO Schiphol BIC/SWIFT: ABNANL2A IBAN: NL21ABNA0515047775)

Payment by Credit Card (Service charge for online-payment: € 2.50)

Cancel