5th European Congress on Violence - Congress Registration Form

Registration Form to the 5th European Congress on Violence in Clinical Psychiatry

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 Congress Amsterdam Dinner Cruise.

	Before 1-8-2007	Before 1-8-2007	After 31-7-2007	After 31-7-2007
	Bank transfer	Creditcard (+5%)	Bank transfer	Creditcard (+5%)
Congress fee	€ 525,-	€ 551,-*	€ 575,-*	€ 603,-*
EVIPRG member	€ 475,-	€ 499,-*	€ 525,-*	€ 551,-*
Congress Amsterdam Dinner Cruise Number of persons: x	€ 75,- = € ,-	€ 79,- = € ,-	€ 75,- = € ,-	€ 79,- = € ,-
Total	€ ,-	€ ,-	€ ,-	€ ,-

	Mr Ms
First Name:
Family Name:
Street:
Post ZIP Code:
City:
Country:
Tel.:
Fax:
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Payment (no cheques)


*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 2007. 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 € ,-.
		Signature:
Name Card Holder:
Card Number Visa / Master / Amex:
Expiry date:
Card Verification Code (CVC):
Date (date/month/year):