Registration Form

Title
Select one... Mr. Mrs.

Name and Surname

I am a member of:

• EURAPS
• AAPS
• the National Society of Plastic Surgeons

I am a resident in training (a letter by the Head of the Department will be sent to the EURAPS Central Office)
I am a research fellow sponsored by the following plastic surgeon: Prof./Dr

Address

Postal code

City

Country

Telephone

Fax

Email

Accompanying person(s) title
Select one... Mr. Mrs.

Accompanying person(s) (first name + last name)

Registration fee includes : scientific sessions, welcome reception, coffee breaks, lunches, gala dinner and farewell party.

Credit card Visa Mastercard

Name

Number

Expiry date

Credit card security code

(three digits at the end of the signature panel)

Cheque will be sent by regular mail to the order of: EURAPS

Prof. A. Banic
Dep. of Plastic Surgery, F-125
Inselspital
CH-3010 Bern
Switzerland

Note: Add € 10 for bank expenses

Cancellation
Refunds, minus administration costs, will be dealt with after the event. Notification of cancellation should be sent to the EURAPS Central Office, euraps@umcutrecht.nl.
If the cancellation is received before May 1, 2009, an administration fee of € 25 per registration will be charged. If cancellations are received after May 1, 2009 the whole fee can be charged.