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31st Annual Scientific Meeting of the Belgian Society of Cardiology

2nd and 3rd February 2012
SQUARE - Brussels Congress Centre

Glass Entrance, Mont des Arts/Kunstbergstraat
1000 - Brussels, Belgium

Registration Form



   
Firstname* :
Lastname (Prof./Dr/Mr/Mrs) * :
Address* :
Post code* :
City* :
Country* :
Phone* :
Fax :
e-mail* :

Attendance (Please tick) :
 
  • Thursday 2nd February :

 

Meeting
  Buffet Lunch
  Evening entertainment & prize presentations
Cocktail in the Exhibition Hall, followed by buffet dinner, prize presentations & entertainment in the Panoramic Hall (5th floor) from 18:00 to 22:30. The Cost for partners is 75€.
  Accompanying partner (75 Euros)
  • Friday 3rd February :

 

Meeting

 

Buffet Lunch

  • Subtotal :

 

Euros

  • Registration fee (Please tick and fill in subtotal) :

 

Non-members (200 Euros)

 

BSC ordinary and extraordinary members (100 Euros)

 

BSC aspirant members, trainees & nurses (25 Euros)
   

 

Partner fee for evening social event on 2nd February
75 Euros x persons

  • Subtotal :

 

Euros

  • Room reservation : Please specify your choice of hotel, room type and nights required and fill in subtotal)
  Hotel:
 

Hotel Le Meridien

  Single room 245 Euros
Double room 275 Euros
 

Hotel SAS Radisson

  Single room 180 Euros
Double room 200 Euros
  Prices are all per night and include breakfast
  Arrival Date (dd/MM/YYYY) :
  Departure Date (dd/MM/YYYY) :
  for night(s) X single/Double
  Single room (per night, including buffet breakfast)
  Twin room (per night, including buffet breakfast)

  Subtotal = Euros


  Total (Attendance + Registration fee + Hotel) = Euros

  • Comments:

  • Payment mode*:
  Payment should be made before 27th January, 2012. Please indicate payment method.
   
  Bank transfer to account N°068-2341598-45 at the Dexia Bank - IBAN BE 44 0682 3415 9845
  Payment by credit card
 
VISA EUROMASTER CARD AMEX DINERS
 
Credit card number :

Expiry date :