REGISTRATION ForM

Please return this form before September 12th, 2016 by post to :

MCO Congrs - ESSFN - Villa Gaby 285 Corniche JF. Kennedy - 13007 Marseille, France
By Fax : +33 (0) 9509 38 01 - or by e-mail : mary.abbas@mcocongres.com

First Name...................................................Last Name......................................................................................................

Address ....................................................... ......................................................................................................................
....................................................................City ................................................................................................................
Postal/Zip Code ...........................................Country ..........................................................................................................
Phone..........................................................Fax .................................................................................................................
Email (compulsory for confirmation) ........... ......................................................................................................................
congress REGISTRATION
Registration Fees Including : Attendance to all scientic sessions & exhibition, opening reception, congress Documentation, Delegates Bags, coee breaks
Early until 13July 2016
Late From 14 July 2016
Physicians (Members)
Physicians (non Members)
residents (Members)
residents ( non Members)
nurses/ students
Accompanying persons
other category

475
630
265
370
85
200
500

I will attend the Welcome reception

525
735
315
420
105
250
600

I will not attend the Welcome reception

Cancellation Of Registration : Any cancellation should be made in writing by e-mail or fax. A 50% refund is available
for cancellations received before August 15th, 2016. After this date no refund will be possible.
PAYMENT : Payment should be made in euros, payable to Mco. Please indicate "essFn 2016" and your name on all money transfers.

Total charge : ................................................

credit card

VIsA

AMeX

MAsTercArD

card number : .................................................... expiry Date : .........../...............

cardholder name : ............................................. security number : .........................
I authorise Mco congrs, the ocial congress organiser to charge the amount to my credit card
By bank transfer :
Bank : BAnQUe PALATIne - Marseille grigan - rIB 40978 00023 1111784V001 73 - IBAn Fr15 4097 8000 2311 1178 4V00 173
BIc BsPFFrPPXXX

sIgnATUre & DATe: