PARTICIPANT REGISTRATION FORM



PARTICIPANT REGISTRATION FORM

EFGCP Multi-Stakeholder Workshop on

Communicating Clinical Trial Results to Meet Public Needs

- A Meaningful Future for Lay Summaries -

29 May 2015, Thon Hotel EU, Brussels, Belgium

|Please use CAPITAL LETTERS or TYPE and return this form to: |

|conferences@efgcp.eu • Fax: +32 2 503 31 08 |

|EFGCP Secretariat – Rue de l’Industrie 4, BE-1000 Brussels, Belgium - Tel.: +32 2 732 87 83 • efgcp.eu |

Registration Details

Mr. Ms. Dr. Prof.

Family Name: First Name:

Position: Department:

Organisation/Company:

Address:

Zip code: Town: Country:

Phone: Fax:

Email:

Specific diet requirements (vegetarian, allergies …): …………………………....................................................................

If you need any other specific facilities (wheelchair access …), do not hesitate to inform the EFGCP Team.

Registration Fee

Become an EFGCP member when registering to this workshop and benefit from the discounted members’ rate from now on (further details are available on the membership webpage).

| |Members of |+ VAT 21% |Non-Members |+ VAT 21% |

| |EFGCP-EFPIA | | | |

|Registration Fee |

|Account Holder: |EFGCP Events |Bank Name: |ING, Brussels, Belgium |BIC/Swift |BBRUBEBB |

|Account #: |310-1960818-49 |IBAN: |BE97 3101 9608 1849 |Communication |Invoice # |

| | | | | |Delegate’s name |

For payments by Bank Transfer: to comply with new EU invoicing rules as of 01/01/21013, a pro forma invoice will be sent along with the confirmation of registration. Once payment is received (prior to the event!), the official invoice will be issued.

| CREDIT CARD: American Express Mastercard VISA |

|Cardholder: | |Amount: | …………….…….…….+……….………VAT |

|Card #: | |Expiry date: | |Security Code (CVC): | |

|Date: | |Signature: | |

| | | | |

For payments by Credit Card: The official invoice will be sent upon receipt of payment from the Credit Card operator.

Billing and VAT Information

Organisation/Company:

VAT #:

IF DIFFERENT FROM ABOVE:

Contact Person:

Position: Department:

Address:

Zip code: City: Country:

Phone: Fax:

Email: Purchase Order # or other reference:

IMPORTANT: Hotel and travel reservations should be made ONLY after receipt of written registration confirmation from EFGCP. If you have not received your confirmation within five working days, please contact the EFGCP Secretariat.

Data Protection Statement & Personality / Image Rights

By filling out the registration form, the participant gives consent that EFGCP can process the data provided within the framework of the conference and allow photographs to be made during the conference. This includes, unless registered participants object, all handling needed for the applicant’s participation at the event and for the drafting of a list of participants which will be distributed at the conference, and placing photographs in the pictures gallery accessible only by participants and EFGCP members, in the EFGCP newsletter or selecting some for articles on the conference in a journal or newspaper, or in any other web/printed publication.

Right of access: applicants have a right to access and ask for changing or deleting their personal data, which will be kept by EFGCP.

EFGCP would like to contact you occasionally to keep you informed of future EFGCP events and other relevant information. If you do not wish us to do this, please tick this box to be removed from our general distribution list

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