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REGISTRATION FORM13th European Head and Neck Course
14 – 16 January 2021, ON-LINE
First Name
Last Name
Job Title
Department
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: [email protected]
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:[email protected] ; [email protected]
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: [email protected]
