Congress Registration Form to the 2007 Foundation Congress of HORATIO - European Psychiatric Nurses
 

Please send (or fax to + 31 20 409 0550) your completed registration form and indication of your payment to:
Horatio Congress 2007. c/o Oud Consultancy & Conference Management. Hakfort 621. 1102 LA Amsterdam. The Netherlands.
 

Congress fee for two days
Please tick the appropriate boxes.

	Conference fee
	Payment by bank transfer	€ 299,-
	Payment by credit card (+5%)	€ 314,-

Title

First Name

Family Name

Street

City

Post ZIP Code

Country

Tel

Fax

E-mail

Workshop attendance (please tick the appropriate box)

Session 1  (1)     (2)     (3)    (4)    (5) Session 2  (1)     (2)     (3)    (4)    (5)

Payment (no cheques)

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 Horatio 2007. For international payments use our ( IBAN) International Bank Account Number: NL56INGB 0681 3061 57, and (BIC) Bank Identity Code: INGBNL2A.

Please send me a bill.

I authorise Oud Consultancy & Conference Management to debit my credit card for € ,-.

Please select credit card:                   Visa Card Master Card American Express

Card Number Visa / Master / Amex:                                              Signature:

Expiry date:

Card Verification Code (CVC):

Date (date/month/year):