Registration Form for the Sixth International Conference on Violence in the Health Sector 2018

 

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 / Dinner fees (inclusive 13% Ontario GST/HST rate)
Please tick the appropriate boxes and fill in with how many persons you will attend the Conference Dinner.

Congress fee

Early Bird

Early Bird

Before
1-8-2018

Before
1-8-2018

After
31-7-2018

After
31-7-2018

Country Category

Bank transfer

Creditcard

Bank transfer

Creditcard

A (see reference)

€ 695,-

€ 730,-

€ 745,-

€ 780,-

B (see reference)

€ 595,-

€ 625,-

€ 645,-

€ 675,-

C (see reference)

€ 495,-

€ 520,-

€ 545,-

€ 570,-

D (see reference)

€ 395,-

€ 415,-

€ 445,-

€ 465,-

Fee is being waived

€ 000,-

€ 000,-

€ 000,-

€ 000,-

Conference Dinner fee

Number of persons: x

€ 95,-

= € ,-

€ 100,-

= € ,-

€ 95,-

= € ,-

€ 100,-

= € ,-

Total

€ ,-

€ ,-

€ ,-

€ ,-


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 Sixth 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.

  

Mr     Ms

First Name:

Family Name:

Street:

Post ZIP Code:

City:

Country:

Tel.:

Fax:

E-mail:

 

Payment (no cheque)

Please select payment method:

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 2018.

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:

item1

Card Number Visa / Master / Amex:

Expiry date: (month/year)

Card Verification Code (CVC):

Date (date/month/year):

 

    

 

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