31st Scientific Meeting
28 March 2014, Lamot, Mechelen

Registration form in word

Personal details (please do not mix your working address and private address)
 
Family / Last name *
First Name *
Title*
Institute
Department
Street and number *
Postal code and city *
Country *
E-mail *
Telephone
Fax
Date of birth
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Registration part (participation fee includes BSRM membership 2014)
Amount in euro including 6% VAT
I want to participate in the meeting
55 Euro (clinician - biologist) - membership included
  25 Euro (paramedical - resident in training) - membership included  
  Free - Membership 2014 already paid-up  
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Invoice details (only complete, if you want to receive an invoice. The invoice will be sent after receipt of payment)
Title + First name + Last name
Institute
Department
Street and number
Postal code and city
Country
Vat N°
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Payment policy
Full payment has to be made to the BSRM account 310-1263178-33 with reference: Name + 31st Scientific Meeting.
IBAN number: BE79 3101 2631 7833 • BIC: BBRUBEBB • Bank: ING

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The details of the previous meetings can be found under Archives