Registration Form

 

2000 Annual Conference of the Association of Medical Schools in Europe

Medical School of the University of Porto, Portugal

Portugal, Porto, September 3-5, 2000

175th Anniversary of the Medical School of Porto

REGISTRATION FORM

Please complete and return this form (Microsoft Word format), together with your payment, to:

Secretariat
AMSE 2000 Conference
ACRÓPOLE, Lda.
Avenida Mouzinho da Silveira, 16
Gueifães. 4470-090 Maia
Portugal
Tel: 351-22-9412406 Fax: 351-22-9412407
Email: acropole@esoterica.pt

 

Fees for PARTICIPANTS include:

Fees for ACCOMPANYING PERSONS include:

 

This is a Copy of the registration form

Identification

Please complete this section accurately; the information you provide will allow us to correspond with you efficiently, and it will also be used for your delegate badge at the Conference.

Participant (Please TYPE or PRINT IN BLOCK LETTERS)

Surname   Initials
First Name
Title o Prof. o Dr. o Mr. o Mrs. o Ms.

Address for List of Participants’ Purposes:

Institution   Department
Nº Street Suite/Apt.
City State/Province Country Postal Code
  Email address

Mailing Address If Different From Above:

Nº Street Suite/Apt.
City State/Province Country Postal Code

Accompanying persons

List only those individuals registering for the Accompanying Persons’ Program:

Surname   First name   Title
Surname   First name   Title
Surname   First name   Title

 

Registration Fees

Please check in the appropriate box/s

 

Until June 16, 2000

After June 17, 2000
AMSE members o 40.000 PTE (200 EUR) o 48.000 PTE (240 EUR)
Non members o 50.000 PTE (250 EUR) o 58.000 PTE (290 EUR)
Students o 20.000 PTE (100 EUR) o 25.000 PTE (140 EUR)
Accompanying persons o 25.000 PTE (125 EUR) o 25.000 PTE (125 EUR)
AMSE membership fee o US $200 (in a separate cheque)

Payment

Please indicate amount enclosed and ensure that you send your fully completed registration form together with your payment:

Total fees: ____________ PTE (EUROS)

Method of payment

Option 1: Bank Transfer – with your name and address indicated on the reverse. If payment is made for more than one person or by a company please make sure all names are indicated and send fully completed registration forms together with a copy of the bank transfer. Please make drafts payable to: Faculdade de Medicina do Porto - AMSE 2000 and send them to Caixa Geral de Depósitos – Balcão Areosa – NIB 003501030002712353030. Bank charges are the responsibility of the payee and should be paid at source in addition to the registration fees.

Option 2: Cheque made payable to: Faculdade de Medicina do Porto - AMSE 2000

Enclosed cheque number: ____________________________ Bank: ____________________________________

Please include fully completed registration form.

 

Cancellation policy

Refund of Registration Fees will be made as follows:

Post-marked prior to June 16, 2000 – full refund less US$ 40 handling fee

Post-marked from June 17, to August 4, 2000 – 50% refund

Post-marked after August 4, 2000 – no refund

Date ______________________________________ Signature _______________________________________