the Registration form in PDF

International Summer Course
23-25 June 2016
Novarello Congress Center
Granozzo con Monticello, Novara (Italy)
INTRINSIC
AND INNATE
IMMUNITY TO
PATHOGENS
REGISTRATION FORM
Please return this form to the Congress Organizing Secretariat
OIC srl - Viale Matteotti 7, 50121 Florence, Italy – by 10 June 2016
Phone +39 (055) 50351, fax +39 (055) 5035230, e-mail [email protected]
MAIN PERSONAL INFORMATION
Please complete this form for ONE participant in block letters.
 Prof.  Dr.  Mr.  Mrs.
 male  female
Last name ________________________________________ First name ___________________________________________________________
Institution ___________________________________ Unit, suite, floor ___________________________________________________________
Work e-mail address _____________________________________________________________________________________________________
PARTICIPANT INFORMATION
Postal Address __________________________________________________________________________________________________________
Postal code ______________________________ City ___________________________________________________________________________
Country ________________________________________________________________________________________________________________
E-mail (mandatory) ______________________________________________________________________________________________________
Telephone ____________________________________________ Telefax ___________________________________________________________
Fiscal Code (mandatory for Italian participant only) __________________________________________________________________________
Date and Country of birth (mandatory for foreign participant) _________________________________________________________________
BILLING ADDRESS (if different from personal information)
Please head receipt of payment/invoice to:_______________________________________________________
_____________________________________________________________________________________________
(address, zip code, city, country)
Fiscal licence / VAT code (MANDATORY FOR COMPANIES) _________________________________________________________________
I accept to receive the invoice: q by email as a PDF file - or -
q hard copy by post
REGISTRATIONS
The latest date for pre-registration is 10 June 2016. After this date, please register on site.
REGISTRATION FEES
Early registration
by 14 April 2016
From 15 April
to 15 May 2016
From 16 May
and on site
¨ Participant_Code A
€ 550,00
€ 600,00
upon availability
¨ Participant_Code B
€ 450,00
€ 500,00
upon availability
¨ Participant_Code C
€ 320,00
Registration fee _CODE A includes:
-
one double room for single use for 2
nights – IN 23 OUT 25 June 2016, city
tax not included*
- welcome reception on 23 June 2016
- nr. 3 coffee breaks
- nr. 2 lunches
- social dinner on 24 June 2016
Registration fee _CODE B includes:
-
one double room for 2 nights to
SHARE with another participant – IN
23 OUT 25 June 2016, city tax not
included*
- welcome reception on 23 June 2016
- nr. 3 coffee breaks
- nr. 2 lunches
- social dinner on 24 June 2016
€ 350,00
Registration fee _CODE C includes:
- welcome reception on 23 June 2016
- nr. 3 coffee breaks
- nr. 2 lunches
- social dinner on 24 June 2016
* The reservation will be booked at the Hotel Novarello located in the same area of the Meeting Venue.
* For Code B: I will share the room with ___________________
Registrations CODE_A and CODE_B can be bought until 15 May 2016.
From 16 May 2016 hotel rooms included in registrations code_A and code_B will be handled upon availability.
International Summer Course
INTRINSIC
AND INNATE
IMMUNITY TO
PATHOGENS
23-25 June 2016
Novarello Congress Center
Granozzo con Monticello, Novara (Italy)
¨ I will apply for ESCMID grant
Please repeat your Surname _____________________________ Name ___________________________
SUMMARY
I herewith enclose the following amounts:
Registration Fee€ __________________________
TOTAL TO BE PAID € __________________________
PAYMENT
u Please charge the following credit card:
 VISA
 MASTERCARD
 AMERICAN EXPRESS
Card no. ____________________________________________________________ Expiry date _______________________________________
Security code (last 4 digits on the front of the card, AMERICAN EXPRESS only) _________________________________________________
Security code (last 3 digits on the back of the card, VISA and MASTERCARD only) ______________________________________________
Cardholder’s name ______________________________________________________________________________________________________
Overall amount (total) to be charged in EUR (€) _____________________________________________________________________________
I hereby authorise the use of my credit card for the purposes specified above.
Date Signature
____________________________
__________________________________
u Payment by bank transfer:
Account name: OIC srl
Bank: Cassa di Risparmio di Firenze, Ag. 1, Viale Matteotti 20r, 50132 Florence, Italy
IBAN Code: IT39 S061 6002 8010 0001 0628 C00 – SWIFT Code: CRFiiT3F
No charges to the recipient.
A copy of the bank transaction has to be sent together with the registration form to OIC Srl by fax or e-mail.
The sender’s full name and address must be clearly stated in the transfer order as well as the payment purposes.
IMPORTANT NOTICE
Registrations can be considered valid only after receipt of the payment.
Forms without proof of payment will not be processed.
Nota per FATTURAZIONE alle Pubbliche Amministrazioni (for Italian participant only):
1) Per poter ricevere fattura intestata ad un ente pubblico ed emessa con Scissione di pagamento (addebito dell’IVA in fattura alla P.A.) dovrà essere inviato direttamente dalla
P.A. l’ordine di acquisto, riportante il codice univoco PA (Identificazione Pubbl. Ammin.) attribuito ad ogni singola unità
organizzativa (UO), ed ogni altra eventuale informazione che l’Ente stesso ritenga necessaria ed opportuna per facilitare l’identificazione del pagamento del servizio come da
norma della fatturazione elettronica.
2) Per poter ricevere fattura intestata ad un ente pubblico ed emessa con esenzione IVA ai sensi dell’art. 10 del DPR 633/72 come modificato dall’art. 14, comma 10 della legge
24 dicembre 1993 n. 537, dovrà essere inviata, unitamente alla scheda di iscrizione, una dichiarazione scritta dalla P.A. (contenente tutti i dati fiscali dell’Ente, oltre al codice
univoco PA) in cui si specifichi che il dipendente (indicare nome e cognome) è autorizzato a frequentare l’evento per aggiornamento professionale; oltre ad ogni altra eventuale
informazione che l’Ente stesso ritenga necessaria ed opportuna per facilitare l’identificazione del pagamento del servizio come da norma della fatturazione elettronica.
IN MANCANZA DELLA DOCUMENTAZIONE RICHIESTA E SOPRA DESCRITTA NON POTRANNO ESSERE EMESSE FATTURE INTESTATE AD ENTI PUBBLICI; in questo
caso il pagamento dovrà essere inclusivo di IVA e la fattura verrà intestata al partecipante.
IMPORTANT
According to the Italian Law Art.13 D.Lgs. 196/2003, I authorize OIC srl to use my data for marketing and commercial purposes, therefore to communicate
me promotional and advertising messages and activities in connection to the Congress.
 I agree
I authorize OIC srl to use my data for marketing and commercial purposes, therefore to send me promotional and advertising messages and information
about activities in connection to the Congress.
 I agree
 I do not agree