BIWAC registration form
Prof.
Dr.
Mr.
Ms.
* mandatory fields
Family name:
*
Name:
*
Hospital/Company:
*
Address:
*
Postal Code:
*
Town:
*
Phone:
*
Fax:
E-mail:
*
Registration fee:
Doctor: 50€
Trainee, Nurse, Technician: 25€
Industry: 100€
Will attend the 2nd Belgian Congress on Acute Cardiac Care and pays by bank transfer to the order of Downtown Europe; ING Bank Account No. 363-4258593-42
Will attend the congress and is invited by
(Name of Sponsor Company)
Will travel to the congress by car and requests a free parking for the day (Parking Manhattan - Rue des Croisades/Kruisvaartenstraat)