First Name*

Family name*

Email address*

Mobile Phone*

Place of birth*

Date of birth (YYYY-MM-DD)*

Codice Fiscale / Vat Number / Passport Number*

Nationality*

Private Address*
Street - Town -Zip Code - Country

Hospital*
Affiliation and department

Hospital address*
Street - Zip Code - Town - Country

Do you need VISA?*
 yes no

If you need Visa send Passport Number - date of issue and date of expire

ESSU Course Registration FEE*
Registration fee is per person and includes admittance to the course, quick lunches, certificate of attendance
 € 500,00 + VAT 22%

Select ESSU Course Registration*
March 15/17, 2017

ESSU Course - Hotel Reservation*
Do you need the Hotel Reservation?
 yes no

ESSU Course - Hotel Proposals
the fee of the Hotel is VAT excluded
 H2C hotel Milanofiori 4* - € 170,00 one night staying in Double Single Use Room - Free private transfer from the hotel to the congress venue and back - Assago (MI) hotel located in a commercial area, close to the course venue, very close to the underground Ata Hotel Quark 4* - € 180,00 one night staying in Double Single Use Room - Free private transfer from the hotel to the congress venue and back - City Tax Included - Hotel in Milan, close to the course venue Milano 3 Excel Hotel 4* - € 155,00 one night staying in Double Single Use Room - Free private transfer from the hotel to the congress venue and back

Transfer Reservation*
Private Transfer from the airport and back with our driver
 Yes, I'd like to reserve the service - € 200,00 No, I'm not interested

Course Registration FEE - Payment*
Bank transfer to: Materia Prima Srl c/o - Bank name: UBI BANCA - BANCA POPOLARE DI BERGAMO - IBAN IT 06 V 03111 11101 000000008533 – Bic/SWIFT: BLOPIT22 - Please make reference to ESSU COURSE. The Registration fee is considered without VAT.
THE ORGANIZING SECRETARIAT WILL SEND YOU AN EMAIL WITH ALL THE DETAILS OF YOUR RESERVATIONS AND THE TOTAL AMOUNT TO BE PAID - THE TOTAL AMOUNT TO BE PAID IS NET OF BANK CHARGES.
 I read it and I accept the payment conditions

INVOICE HEADING and Notes*
Society/Participant/Institution - Address - Zip code - Town - Country - Codice fiscale/NIF/ Tax number/VAT number/Passport number (compulsory for invoicing)

Pursuant Information On Law 196/2003*
MATERIA PRIMA SRL Srl, as data controller and/or processor, informs you that any personal data you provide, or any data received by third parties, will be used in connection to your participation to the Congress and/or to provide you with information regarding any other compatible activities organized by MATERIA PRIMA SRL or by its associates. Data treatment shall mean any operation, or set of operations, carried out with or without the help of electronic or automated means, and must guarantee the confidentiality and security of your personal data. MATERIA PRIMA SRL Srl, as data controller and/or processor may avail itself or its associates to carry out any of the following procedures: press releases, communications to clients, data processing and computer-based consultation. The data can be communicated to scientific associations, relative public or private agencies related to CME , financial and banking intermediaries, as well as companies participating in the Congress with promotional functions compatible with the purposes for which the data has been collected. The provision of your personal data is voluntary, but refusal will prevent your participation to the Congress. Under section 7 of the Legislative Decree no. 196 of 30 June 2003 you have the right to object to the processing of your personal data for the purposes relevant to the collection, for purposes of sending advertising materials or direct selling or else for the performance of market or commercial communication surveys. Any requests can be addressed to: MATERIA PRIMA SRL Srl - Via Martiri di Cefalonia 6, 24121 Bergamo - I authorize the treatment and communication of my personal data as described above.
I read and I agree