IUSG/ICO –Uveitis Course Venice 2013 Registration Form

IUSG/ICO –Uveitis Course
Venice 2013
Registration Form
First Name: Last Name:
Affiliation:
Mailing Address:
City/State/Zip:
Country:
Phone: Fax: E-Mail:
Date of Arrival: Date of Departure:
Registration fee:
includes Course material and accommodation for 7 nights (9. – 16. February
2013)
Accommodation:
I would like to have a single bedroom 1.600 €
I would like to have a double bedroom 1.500 €
I share the double bedroom with the
participant:
Payment detail:
For money transfer in Germany:
Name:
Bank: Landesbank/Baden-Württembergische Bank
Empfänger: Universitäts-Klinikum Tübingen
BLZ: 60050101
Konto-Nr.: 7477503793
Verwendungszw.: 33.03225

Kostenstelle: 9221905
Stichwort: Venedig 2013
For money transfer outside of Germany:
Bank: Landesbank/Baden-Württembergische Bank, Stuttgart
Receiver: University of Tuebingen
BIC: SOLA DE ST
IBAN-No: DE41 6005 0101 7477 5037 93
Please add: D.33.03225, 9221905
Reg: Venice 2013
To be completed and returned to:
Marina Körner-Zierhut
Secretary of Prof. Zierhut
Schleichstr. 12 – 16
72076 Tübingen
Germany
or:
Fax: +49 (0) 7071/29 4762
marina.koerner-zierhut@med.uni-tuebingen.de
Cancellation charges
Cancel before October 31 st 2012 - 80% reimbursement
Cancel before December 31 st 2012
- 30% reimbursement
Date: Signature