European Head and Neck Courseeurohnc.com/docs/registration form.docx · Web viewCourse Office Kinga...

REGISTRATION FORM13th European Head and Neck Course

14 – 16 January 2021, ON-LINE

First Name

Last Name

Job Title

Department

Email

Telephone

Billing

Course Office Kinga Lunitz – Course Coordinator

13th European Head and Neck Course15 Garbary St., 61-866 Poznan

Phone: +48 61 88 50 929; fax: (+48 61) 88 50 910e-mail: kinga.lunitz@wco.pl

I have paid the registration fee:

☐ €30 (120 PLN) registration fee for the European Head and Neck Society Members and Polish Head and Neck Society Members

☐ €50 (200 PLN) gistration fee for non-Members

PAYMENTS IN EURO:Polish Society of Head and Neck CancerTitle: Eurohnc2020; Name of the bank: mBankBank address: BRANCH POZNAN, 42 Polwiejska Street, 61-888 PoznanIBAN: PL 49114011240000270055001002BIC/Swiftcode: BREXPLPWMBK

PAYMENTS IN PLN:Polskie Towarzystwo Nowotworów Głowy i SzyiTytułem: Eurohnc2020; Nazwa Banku: mBankAdres Banku: ODDZIAŁ POZNAN, ul. Półwiejska 42, 61-888 PoznańIBAN: PL 11114011240000270055001007BIC/Swiftcode: BREXPLPWMBK

Definitive registration only if full payment has been received

Date Signature

Please send the completed form via:

e-mail:ehnc@wco.pl ; kinga.lunitz@wco.pl

fax: +48 61 88 50 910

Course Office Kinga Lunitz – Course Coordinator

13th European Head and Neck Course15 Garbary St., 61-866 Poznan

Phone: +48 61 88 50 929; fax: (+48 61) 88 50 910e-mail: kinga.lunitz@wco.pl