Registration Form for the International Conference on Workplace Violence in the Health Sector

Please, send (or fax to ++ 31 (0)20 409 0550) your completed registration form and indication of payment to:
Oud Consultancy & Conference Management, Hakfort 621, 1102 LA Amsterdam, the Netherlands.

Conference fees / Dinner cruise
Please tick the appropriate boxes and fill in with how many persons you will attend the Conference Amsterdam Dinner Cruise.

	Before 1-8-2010		Before 1-8-2010		After 31-7-2010		After 31-7-2010
	Bank transfer		Creditcard		Bank transfer		Creditcard
Country Category	Congress fees
A (see reference)	€ 575,-		€ 600,-		€ 625,-		€ 655,-
B (see reference)	€ 475,-		€ 495,-		€ 525,-		€ 550,-
C (see reference)	€ 375,-		€ 390,-		€ 425,-		€ 445,-
D (see reference)	€ 275,-		€ 285,-		€ 325,-		€ 340,-
Conference Amsterdam Dinner Cruise Number of persons: x	€ 85,- = € ,-		€ 89,- = € ,-		€ 85,- = € ,-		€ 89,- = € ,-
Total	€ ,-		€ ,-		€ ,-		€ ,-

I declare that I have read the general information and registration and payment conditions and I agree with the release and waiver of liability policies, the disclaimer, as well as the policies regarding cancellations and registration refunds.

In consideration of my participation in the second international conference on violence in the health sector 2010, I do hereby release, discharge and hold harmless Oud Consultancy from any and all liability by reason of any damage, loss, expense, or injury arising from my participation in this event, including that caused solely or in party by the fault (including but not limited to negligence, gross negligence, and recklessness) of the above-named parties. This release and Waiver of Liability shall be binding on my heirs, executors, administrators, successors, and assigns.

	Mr     Ms
First Name:
Family Name:
Street:
Post ZIP Code:
City:
Country:
Tel.:
Fax:
E-mail:

Payment (no cheque)

Please select payment method:         Bank* Credit card
*I have deposited my payment (free of charges for the recipient) in bank account number 68.13.06.157 of the ING Bank, Amsterdam, The Netherlands, in the Name of Oud Consultancy, Hakfort 621, 1102 LA Amsterdam and have mentioned my Name for VIOLENCE 2010. For international payments use our (IBAN) International Bank Account Number: NL56 INGB 0681 3061 57, and (BIC) Bank Identity Code: INGBNL2A.
I authorise Oud Consultancy & Conference Management to debit my credit card for € ,-.
Please select credit card:                   Visa Card Master Card American Express		Signature:
Name Card Holder:
Card Number Visa / Master / Amex:
Expiry date:
Card Verification Code (CVC):
Date (date/month/year):

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