The 2nd Gerry Schwartz and Heather Reisman International Congress on
Chronic Disorders & Disabilities in Children
December 3-4, 2008, Regency Jerusalem Hotel
Jerusalem, Israel
REGISTRATION & ACCOMMODATION FORM
To download the form please see link below
Please type or write in capital Letters and send by e-mail or fax to:
International Travel and Congresses
82 Menachem Begin St., Tel-Aviv67138
Tel. 972-3-7610813/4/6/ 972-3-7610792, Fax. 972-3-7610791
e-mail: elisheva@internationaltc.co.il
An acknowledgement will be sent to you upon receipt of this form. If you do not receive confirmation of the services requested within 10 days, please contact International Travel and Congress.
PERSONAL CONTACT INFORMATION
Mrs. Surname _______________________
Mr.
Dr.
Prof.
Title: First Name __________________________
Institution
Residence
Mailing Address:
_____________________________________________________________________
City _______________ State/Pro _____________ Zip Code _______Country ___________
Telephone (Working Hours) _______________ Fax_____________ Telephone (Home) _____________________
Email address: _______________________________________________________________
REGISTRATION - Kindly mark the appropriate checkbox
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Until October 15, 2008 |
From October 16, 2008 |
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Participant- Physicians |
EURO 395 |
EURO 450 |
|
Healthcare Professionals |
EURO 300 |
EURO 350 |
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Resident Phsysician/Student(*upon a valid certificate / letter of Department) |
EURO 250 |
EURO 300 |
ACCOMMODATION - Kindly mark the appropriate checkbox
Please make the following reservation
Double room * sharing with
Single room
________________________ (mandatory field in order to book a double room)
Check in date:_____/_______/_____ Check out date: ______/______/ ______ Total nights: _____________________
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Single Room on
Bed & Breakfast Basis |
USD 150 per room per night |
|
Single Room on
Half Board Basis |
USD 188 per room per night |
|
Double Room on
Bed & Breakfast Basis |
USD 175 per room per night |
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Double Room on
Half Board Basis |
USD 220 per room per night |
**Hotel Rates are based on exchange rate of USD 1 = NIS 3.3 and will be charged accordingly
PAYMENT METHOD
Enclosed is cheque No.__________ for the amount of USD - payable
to: International Travel and Congresses
Enclosed is a copy of my bank transfer for the amount of USD
_______ or equivalent - payable to: International Travel andCongresses, Otsar Hahayal Bank (14), Branch No. 357, Account No.38215 / IBAN IL11-0143-5700-0000-0013-603 / Swift: OTSHILIT (Please ensure that your name appears on the bank transfer).
Please charge the amount of USD _________ to my credit card:
Mastercard
Diners Club
Visa
American Express
Credit Card Number_________________________________ Name of Card Holder_______________________
ID/Passport No. of Card Holder_________________________ Authorized address of Card Holder__________________________ Registration forms without payment information will not be accepted.
- Last date for submission of form - November 25 2008. Thereafter you will be able to register at the conference.
- I accept the Congress Registration and Hotel Reservation Cancellation Policy as follows:
Faxed, electronically mailed or post-marked:
Cancellation received prior to November 25, 2008 - full refund less 25%. No refund for cancellations received after this date.
Signature _________________ Date__________________________
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