Registration Form

CONGRESS XXXX

rEGISTRATION FORM

* Indicates required field

Family Name *

First Name *

INVOICE HEADING *

Address *

Post code *

City *

Country *

Phone *

Mobile *

Fax *

VAT o Codice Fiscale*(Only for italian Company/Persons) *

e-mail *

Registration *

Fee € XXXX

EXCURSIONS *

Excursion A € XXXX Excursion B € XXXX Excursion C XXXX

GALA DINNER *

Gala Dinner € XXXX

Food Intolerances *

TOTAL € *

PAYMENT *

Bank Transfer to “STUDIOCONGRESS sas” –XXXXX BANK – Naples (ITALY)
IBAN XXXXXXXXXX SWIFT XXXXXXX
specifying as reason for payment "Participation in XXXX CONGRESS + Name of Participant"
Please, send a copy of the transfer to [email protected]

CREDIT CARD *

MASTERCARD VISA

Number *

Cardholder *

Expiry Date ( mm/aaaa ) *

Secure Code *

Authorization *

I authorize the payment

Pursuant to art.13 of the legislative decree 196/2003 and successive amendments, I hereby express my consent to the processing of my personal data by Studiocongressto the following purposes. I also confirm that I accept the canellation policy.

Choose Any *

I accept

Date *

Via dei Mille 16, 80121 Napoli
Tel. 081 18891223 / Fax 081 18891224
e-mail: [email protected] www.studiocongress.it

INVIA