Registration

I hereby register for the IPPNW public congress “Medicine & Conscience" Erlangen, October 14 – 15, 2011.

Title:

First name*:

Surname*:

Profession:

Address*:

Zip code, Town/City*:

Telephone:

Please enter a correct e-mail address. Confirmation of your registration will be sent to this address:

E-mail*:

Congress fee:

Before 15 Sept. 2011

60,00 € Congress fee

30,00 € Reduced fee (students, school pupils, trainees, unemployed)

100,00 € Supporting fee

From 16.09.2011 onwards

80,00 € Congress fee

40,00 € Reduced fee (students, school pupils, trainees, unemployed)

100,00 € Supporting fee

I will pay the registration fee of

Accompanying persons:

1. First name and surname:

Type of congress fee for person 1:

2. First name and surname:

Type of congress fee for person 2:

Payment

The congress has to cover its own costs. I want to contribute by supporting the congress with a donation to the sum of

EUR:

The total amount for all participants listed above (fee and donation) of

EUR*:

can be directly debited from my bank account

I hereby give my permission for IPPNW Germany to debit the registration fee from the following account::

Account holder:

IBAN (International bank account number):

SWIFT-BIC (Bank International Code)

Name of bank:

I will pay the above total amount by bank transfer

to IPPNW Germany’s bank account:

IBAN (International bank account number) DE39100205000002222210

SWIFT-BIC: BFSWDE33BER

This registration is binding. Should you wish to cancel your participation before 15.09.2011, your registration fee will be reimbursed minus 20% for administration costs. 30% will be retained for a cancellation between 15.09 and 10.10.2011. From 11.10.2011 onwards a cancellation is no longer possible. All documentation will be provided on arrival at the congress venue in Berlin.

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