Registration Form st
41 ISPNE Annual Conference 2011 August 4-6, 2011 - Berlin Germany Attendee Information (Please type or print clearly): Surname:
__________________________________________________________________
First Name: __________________________________________________________________ Mr.
Ms.
Academic Degree
Mrs. Prefix ______________________Suffix _______________________ Student
PhD
MD
Other (describe) __________________________
Company/Institution: ___________________________________________________________________ Department:
___________________________________________________________________
Mailing Address Address:
private
Company/Institution
___________________________________________________________________________
(Street)
Address:
______________________________________________________ Country______________
(Room etc.)
State
______________________ Zip ________________ City _____________________________
Telephone _________________________________________ FAX _____________________________ (including country code)
Email Address _________________________________________________________________________ Role at the Conference (required): General Attendee Rates:
Speaker Until June 2nd, 2011
Student After June 2nd, 2011
Member – ISPNE
$520
$600
Non-Member – ISPNE
$600
$680
Student Rate - ISPNE Member *
$320
$400
Student Rate - non-ISPNE Member *
$400
$450
*Please note that there are a limited number of "Student" spaces available and these will be allocated on a first come, first served basis. In order to qualify for the "Student" fee you must submit a letter from your department head, supervisor or organization confirming your status to the conference organizer at
[email protected].
Would you like join the mailing list of the ISPNE? Yes
No
Contact Hu-Ping Chen, ISPNE-Membership Services Charité Universitätsmedizin Berlin Campus Benjamin Franklin, Department of Psychiatry Eschenallee 3, 14050 Berlin, Germany
Email:
[email protected] Fax: +49 30 8445 8726
ISPNE-Conf 2011-008 fax
Fax-Payment only: +49 30-8445 8726 41st ISPNE Annual Conference 2011 August 4-6, 2011 - Berlin Germany Surname: _____________________________First Name: _____________________________ $ Total Amount Due (in USD):______________________________________________________________ Credit Card (please select): VISA
MasterCard
Card Number:
American Express
_____________________________ Expiration Date: _________ / ________ Month
Year
Cardholder Name: _____________________________ Signature: ____________________________ Billing Address associated with Credit Card: Address
_________________________________________ Country __________________________
State
______________________ Zip ________________ City
__________________________
Telephone _________________________________________ FAX
__________________________
Terms & Conditions
ISPNE reserves the right to cancel a course or to change any part of the program due to unforeseeable circumstances. Cancellation before June 2, 2011 will result in a refund of registration fees minus a $150 administrative fee. Cancellations received on or after June 2, 2011 are not eligible for a refund. Refund requests must be made in writing and submitted to and received by Registration Services via e-mail (
[email protected]). Full payment must be received with your registration to secure your space at the conference. Online payment, VISA, MasterCard and American Express are accepted! Wire transfers are not accepted! For security reasons, please FAX form; do not send credit card number by email! Substitutions are allowed only with written consent of the original registrant. Recording devices and cameras, still or video, are prohibited. ISPNE may be taking photographs of speakers and participants during the conference or may use excerpts of any written materials or correspondence provided by speakers or participants for use in promotional materials.
We encourage you to check the website for updates on the program as well as information on the conference venue, accommodations and travel. If you have any questions, please do not hesitate to contact us at
[email protected]. We look forward to meeting you in August! Note: Go to the hotel registration link on the ISPNE-Website until June 2nd, 2011 to secure reduced room prices!
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Contact Hu-Ping Chen, ISPNE-Membership Services Charité Universitätsmedizin Berlin Campus Benjamin Franklin, Department of Psychiatry Eschenallee 3, 14050 Berlin, Germany
Email:
[email protected] Fax: +49 30 8445 8726
ISPNE-Conf 2011-008 fax
