Registration Form for the Fourth International Conference on 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 (EURO €)
Please tick the appropriate boxes and fill in with how many persons you will attend the Conference bus / boat / bbq evening.
Conference fees are in Euros
|
Before 1-9-2014
|
Before 1-9-2014
|
After 31-8-2014
|
After 31-8-2014
|
Country Category
|
Bank transfer
|
Creditcard
|
Bank transfer
|
Creditcard
|
A (see reference)
|
€ 595,-
|
€ 625,-
|
€ 645,-
|
€ 677,-
|
B (see reference)
|
€ 495,-
|
€ 525,-
|
€ 545,-
|
€ 572,-
|
C (see reference)
|
€ 395,-
|
€ 415,-
|
€ 445,-
|
€ 467,-
|
D (see reference)
|
€ 295,-
|
€ 315,-
|
€ 345,-
|
€ 362,-
|
Fee is being waived
|
€ 000,-
|
€ 000,-
|
€ 000,-
|
€ 000,-
|
Conference bus / boat / bbq evening fee
|
 |
|
|
|
Number of persons: x
|
€ 75,-
= € ,-
|
€ 79,-
= € ,-
|
€ 75,-
= € ,-
|
€ 79,-
= € ,-
|
Total (EURO €)
|
€ ,-
|
€ ,-
|
€ ,-
|
€ ,-
|
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 fourth International Conference on Violence in the Health Sector, I do hereby release, discharge and hold harmless Oud Consultancy and supporting organizations, 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.
Payment (no cheque)
Please select payment method:
I have deposited my payment by return, and free of charges for the recipient in International Bank Account Number (IBAN) NL56INGB0681306157 of the ING Bank, Jan van Galenstraat 14, 1051 KM, Amsterdam, the Netherlands, in the name of Oud Consultancy, Hakfort 621, 1102 LA, Amsterdam, the Netherlands. I have mentioned VIOLENCE 2014, and my name or the name for whom the payment is being paid for.
For some international payments additional information might be necessary:
The ING Bank Identity Code (BIC/SWIFT) is INGBNL2A.
Oud Consultancy VAT number is NL067580725B01
Oud Consultancy Chamber of Commerce number is KvK Amsterdam 34199081
|
I authorise Oud Consultancy & Conference Management to debit my credit card for € ,-.
|
|
|
Signature:
|
Name Card Holder:
|
|
|
Card Number Visa / Master / Amex:
|
|
Expiry date: (month/year)
|
|
Card Verification Code (CVC):
|
|
Date (date/month/year):
|
|
Back
|