TRAVEX CONGRESS MANAGEMENT
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SERVICES

12th SYMPOSIUM ON AORTIC VALVE RECONSTRUCTIVE SURGERY

June 22-23, 2012 / Brussels – Belgium
Aortic Valve Repair : How can you do it ?

Registration Form



   
Title* : Mr Ms Dr
Firstname* :
Lastname* :
Institution :
Address* :
Post code* :
City* :
Country* :
Tel* :
Fax :
E-mail* :

Please read and complete carefully:
 
  • Will attend the meeting and pay* :

 

  The registration fees include : Conference + Lunches
  • Will attend the Gala dinner * :
 

Participant fee for the Gala Dinner
(90 Euros per person) :

X 90 Euros = Euros

 

Companion fee for the Gala Dinner
(90 Euros per person) :

X 90 Euros = Euros


  • Will reserve a room* :
 

First Euroflat Hotel - Single room

(21/6 : 165€/night - 22&23/06 : 105€/night)

First Euroflat Hotel - Double room

(21/6 : 187€/night - 22&23/06 : 105€/night)

Martin's Central Park - Single room

(21/6 : 175€/night - 22&23/06 : 90€/night)

Martin's Central Park - Double room

(21/6 : 195€/night - 22&23/06 : 110€/night)

buffet breakfast included

   
  Arrival Date (dd/MM/YYYY) :
  Departure Date (dd/MM/YYYY) :

  Registration+Hotel+Gala dinner = Euros

  • Comments:


  • Payment mode*:
  Amount to be paid to the Bank Dexia - Swift code : GKCCBEBB - Iban Code : BE29-0682-34520-64 - To the bank account N°068-2341520-64
  Payment by credit card
 
VISA EUROMASTER CARD AMEX
 
Credit card number :

Expiry date :