International symposium on Regulatory peptides 2012

19th International Symposium on Regulatory Peptides

20-23 August, 2012 at LIFE, Copenhagen University, Denmark

First name

Last name

Title

Institution / Company

Department

Address

Postal code

City

Country

Phone

Mobile

Fax

E-mail

Vegetarian

Vegan

Accompanying person

Registration fee

Registered and paid before 1 July, 2012

Registered and paid after 1 July, 2012

Regular fee

DKK 4500 (EUR 600)

DKK 5250 (EUR 700)

Pregraduate or PhD Student

DKK 3000(EUR 400)

DKK 3750(EUR 500)

Invited speaker

DKK 0

Accompanying person

DKK 750(EUR 100)

I have registered for Ph.d course

Social programme

Get together at LIFE on Monday 20th August at 19:00-20:30 incl. in the registration fee

Formal dinner on Wednesday 22nd August - incl in the registration fee

Total

DKK

Payment

Transferred to ”regpep2012”, c/o KongresKompagniet, S.W.I.F.T. DABADKKK, account No. 3643 3632584598, Danske Bank, Holmens Kanal 2-12, DK-1092 Copenhagen K, Denmark. PLEASE state name and “regpep2012”. IBAN: DK33 3000 3632 5845 98

By credit card (please have your credit card ready for online payment)

Electronic invoice (for Danish participants only).

EAN No

EAN personreference

EAN Kontostreg

Cancelling must be in writing and sent to KongresKompagniet. In case of cancellation no later than 15 July, 2012 the full amount less a cancellation fee of DKK 375(50 EURO) will be refunded. In case of cancellation after 15 July, 2012, no refund will be made. Refund claims must include name of the bank, bank address, IBAN, S.w.i.f.t./ BIC code, account number and name of the account owner for money transfers. All refunds will only be processed after the conference

Accommodation

To obtain the stated room prices you must book through the conference secretariat KongresKompagniet by filling in and submitting this form.

Arrival

Departure

I wish to share with

Payment directly to the hotel upon departure. All room prices are per night per room and includes 25% VAT, service charges and breakfast.

Special request

Your registration form is sent to:
KongresKompagniet A/S
Nordhavnsgade 4
8000 Aarhus C
E-mail: regpep2012@kongreskompagniet.dk