European Association of Perinatal Medicine
European School of Perinatal Medicine
(Italy), 22-29 January 2000
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APPLICATION FORM
First name __________________________________
Last name __________________________________
Specialty __________________________________
Mailing address ______________________________
City ______________________________________
Country ___________________________________
Tel. and Fax _______________________________
E-mail ___________________________________
|_| I wish to register to the EAPM Winter Course
Type clearly and return to
EAPM Secretariat
Centre of Perinatal Medicine, P.O. Box 1433,
University Hospital Monteluce,
I - 06122 Perugia, Italy,
Tel. +39 - 075 - 572 0563, 572 0574, Fax: +39 - 075 - 572 92 71
Email: eapm@unipg.it
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REGISTRATION and ACCOMMODATION FORM
Date of arrival ______January 2000
Date of departure ______January 2000
\/ Tick off your choice
I would like to reserve a |_| single room |_| double room
Registrant
______________________________________
______________________________________
______________________________________
Accompanying person
_______________________________________
_______________________________________
_______________________________________
| ACCOMMODATION * | DOUBLE ROOM Per person |
SINGLE ROOM Per person |
Your choice |
| 4 stars Hotel with half board | 70-80 Euro | ** | |
| 3 stars Hotel with half board | 60-70 Euro | ** | |
| 2 stars Hotel with breakfast | 40 Euro | 40 Euro | |
| Apartments on request | |||
| Deposit 3 nights' accommodation | Euro | ||
| Dolomite Super Ski pass | |||
| REGISTRATION FEE 350 Euro | 350 Euro | ||
| TOTAL DUE | Euro |
| |_| Check to C.E.R.S.P.-Ass. Culturale Via Benedetto Croce n. 9 06024 Gubbio (PG), Italy Id. n. 94043700486 VAT number 02341320543 |
|_| Bank draft to C.E.R.S.P. bank account 22407/26 bank codes ABI 06235, CAB 38480 Cassa di Risparmio di Perugia, Agency of Gubbio, P.zza 40 Martiri, 06024 Gubbio (PG), Italy |