PERSONAL DATA

Name * Surname *
Date of birth dd/mm/yyyy Country *
Street * Number *
Town * Zip code *
Phone * Fax
E-mail * VAT code (only for Italian citizens)
Specialized in *    

REGISTRATION FEE, OTHER PAYMENTS AND INVOICING

If registration is free of charge do NOT select any method of payment when asked.
Free of charge**
Total payment in € * local VAT tax included
Total payment in € * local VAT tax not included (for Italian hospitals ONLY)
Reason (for Italian hospitals ONLY)
Select type of fee (more than one choice possible) to select more than one type of payment keep Ctrl key pressed on keyboard

METHOD OF PAYMENT

Check (only Italian checks accepted)**
Bank transfer**
Credit card**  

Heading of invoice
Street Town & Country
Italian VAT number (only for Italian citizens) Italian tax code (only for Italian citizens)
Notes

I authorize the treatment of my personal data to the sense of law 675 on the privacy.
The data will not be shared with other subject different from those who cooperate in providing the requested services .


 

The (*) fields are compulsory
At least one of the (**) fields is compulsory