AMSE ANNUAL CONGRESS 1998 - Prague - 3-5 September 1998

REGISTRATION FORM

Please complete and return to Conference Secretariat by May 31,1998:
Czech Medical Association J.E.Purkyne
Mrs. Jana Dohnalová
Sokolská 31, 120  26 Prague 2
Phone: +420-2-297271, Fax: +420-2-294610

Family name:__________________________________ First name:___________________________________

University of:______________________________________________________ Title:____________________

Address:_________________________________________________________________________________

____________________________________ Country:___________________ Code:_____________________

Phone:___________________________ Fax:_______________________ E-mail:_______________________

Accompanying person(s)_____________________________________________________________________

Registration fees before	before May 31, 1998	after May 31, 1998
AMSE Members	USD 300  	USD 350  
Non Members	USD 350  	USD 400  
Accompanying person	USD 100  	USD 100  
AMSE Membership fee (one per Medical School)	USD 200  

• We will attend the Welcome reception in "Purkyne Institute"
  Thursday, September 3, 1998                                                  ..............person(s)
• We will attend the AMSE Dinner in the restaurant "Vikárka"
  Friday, September 4, 1998                                                      ..............person(s)
• I will attend the Opening ceremony wearing the robe of my University (gown, hat, chain).

Payment:

Payment of the registration fees should be made in one of these ways:

- preferably by the bank transfer to the account of the Czech Medical Association J.E.Purkyne No. 01-61761030/0300,   Congress No. 980 409 with the Ceskoslovenská obchodní banka, Na Príkope 14, 115 20 Prague 1 (one copy should be   enclosed to the registration form)
- by cheque payable to the Czech Medical Association J.E.Purkyne (mailed together with the registration form).
- by credit card

I authorise you to debit my credit card for the total amount of USD.................

VISA     American Express     Euro/Mastercard 

Holder:..........................................................................

Credit Card Number:..................................................... Expiration date:..................

Date:....................................   Signature:.....................................

AMSE ANNUAL CONGRESS 1998 - Prague - 3-5 September 1998