Registration Form for the 9^th 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.

Congress fees / Dinner
Please tick the appropriate boxes and fill in with how many persons you will attend the Congress Dinner.

Congress fees are in EUROS	Bank transfer	Credit Card
Congress regular participant	€ 699,-	€ 729,-
EViPRG / WPA / ENTMA member*	€ 649,-	€ 679,-
Danish buffet, drinks, music & dance
Number of persons: x	€ 75,-	€ 79,-
Total Dinner:	= € ,-	= € ,-
Total:	€ ,-	€ ,-

* EViPRG: European Violence in Psychiatry Research Group
WPA: World Psychiatric Association
ENTMA⁰⁸: European Network for Training in the Management of Aggression

I declare that I am:

           a regular participant
           a EVIPRG member
           a ENTMA member
           a WPA member (please send us by e-mail attachment a copy of your membership card)
 

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 9^th European Congress on Violence in Clinical Psychiatry, I do hereby release, discharge and hold harmless Oud Consultancy and cosponsors, 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 part 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

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, Jan van Galenstraat 14, 1051 KM Amsterdam, The Netherlands, in the Name of Oud Consultancy, Hakfort 621, 1102 LA Amsterdam and have mentioned my Name for VIOLENCE 2015. 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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