Application Form 2016 EBA Conferences Europe Medical Association Special Session 30-31 January, 2017, Dubai, UAE Industry Sector Street address 02 Company details Name of Company as to be written on the Certificate Form Number (don't fill in, for internal use only) 01 Event details City Zip Code Country Contact Phone Mobile E-mail Web-site Last Name Titles Position E-mail Contact Phone Pref. First Name Person, responsible for coordination with EBA Pref. First Name Contact Phone E-mail Company Head details as to be written on the Certificate Last Name 2 Woodin's Way, Oxford OX1 1HF UK - Tel: + 44 (0) 7852 160605 www.awards.ebaoxford.co.uk
Transcript
Application Form 2016 EBA Conferences
Europe Medical Association Special Session 30-31 January, 2017, Dubai, UAE
Industry Sector
Street address
02 Company details
Name of Company as to be written on the Certificate
Form Number (don't fill in, for internal use only)
01 Event details
City Zip Code Country
Contact Phone
Mobile
E-mailWeb-site
Last Name
TitlesPosition
E-mailContact Phone
Pref. First Name
Person, responsible for coordination with EBAPref. First Name
Contact Phone E-mail
Company Head details as to be written on the Certificate
City of the nearest embassy or consulate(If Visa letter required, please, fill in):
Passport No DOB
Pref. First Name
I need a Visa Invitation
No special meal preferences Vegetarian foodMeal preferences:
Last Name
Position Phone for contacts in UAE
City of the nearest embassy or consulate(If Visa letter required, please, fill in): I need a Visa Invitation
Passport No DOB
Pref. First Name
No special meal preferences Vegetarian foodMeal preferences:
Last Name
Position Phone for contacts in UEA
City of the nearest embassy or consulate(If Visa letter required, please, fill in): I need a Visa Invitation
Passport No DOB
Pref. First Name
No special meal preferences Vegetarian foodMeal preferences:
Last Name
Position Phone for contacts in UAE
City of the nearest embassy or consulate(If Visa letter required, please, fill in): I need a Visa Invitation
Passport No DOB
Pref. First Name
No special meal preferences Vegetarian foodMeal preferences:
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Personal Participation GBP Distant Participation GBP
05 Premium Participant Package:
Participation in accordance to Nomination:
07 Extra promo options:
Includes:
06 Extra Participant Package for second and every next representative (650 GBP)Please, indicate number of extra participants
Includes:• Participation in the event programme;• Visit to Arab Health Congress;• The Leaders Times eMagazine subscription;• Complimentary meals and drinks where stated in the session timetable;• Complimentary welcome pack and the forum brochure;• Official visa invitation;• Official forum photos and video (can be downloaded from our web site after event concludes);• Networking with your fellow participants.
Your banner displayed during the forum (banner produced and brought to the forum by participant) (450 GBP);
Promo video played during the forum breaks (30 secs duration max produced and submitted by participant) (250 GBP);
Interview with journalist of eMagazine the Leaders Times (500 GBP).
• 1 person participation in the event according to the programme,visit to Arab Health Congress;
• Visa assistance;• Complimentary meals and drinks where stated in the session timetable;• Complimentary welcome pack and the forum brochure;• Transport service according to the programme;• Winner's certificate, medal and licence;• Honourable certificate ;• 5-year certificate (license) to use the award brand (royalty) for public
relations and marketing purposes;
04 Standard Participant Package: 980 GBP
Personal Participation Only!
Includes: • 1 person participation to all scheduled agenda of the expert visit,
inclusive of the Official reception by EMA President;• Tickets to visit to Arab Health 2017 expo;• Complimentary meals and drinks as stated in the session timetable;• Complimentary welcome pack and the event brochure;• Transport service according to the programme;• Speak up possibility (up to 10 min) for your company/project/
products;• Networking with professional peers;• Round tables with representatives of leading regional clinics;• Your company profile at the official website and social networks;
• Right to use the event pictures and video;• Information about your company (up to 750 characters) in the event
official broshure;• Visa assistance;• Event photo/video materials;• Leaders Times e-Magazine subscription;• Your banner displayed during the special sesssion (banner produced
and brought to the event by participant);• Promo video played during the forum breaks (30 secs duration max
produced and submitted by participant).
• Right to use EBA logo, Rose of Paracelsus Award image;• Right to use the event pictures and video;• Information about your company (up to 750 characters) in the
event official broshure;• Attributes courier delivery to appointed address in case of
distant participation;• Event photo/video materials;• Leaders Times e-Magazine subscription.
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10 Visa, Flight, Transfer, Hotel
For geting visa, flights, as well for accommodation issues, we recommend you contact the travel agencies of your country.
11 Payment options
Currency
Note: All cards are subject to an additional 3% bank charge Refund: All payments are non-refundable, however funds may be used for other EBA service
12 Legal informationThis form is a legal document. Any information you provide will be held securely and in accordance with the Data Protection
Act 1998. Your personal details will not normally be disclosed to third parties.
13 Signature 14 Date 15 Stamp
Please print the completed form, sign and return to us via email, fax or post.
Payment wayInvoice payment Payment by cash with receipt provision Pay by Credit Card
Card type
Signature
Date3 digit security code
First name
Last nameCard number Exp.
date (mm/yy)
Become a member of the International Club of Leaders (ICL), Oxford (1800 GBP)
09 Leader Participant Package
Placement of your advertising and informational materials to 'The Leaders Times magazine':
Leader of the week (250 GBP) Company of the week (250 GBP) Project of the week (250 GBP)
08 Publishing Package:1 page colour presentation article in the Socrates Almanac (A4 format, 3500 symbols, layout produced and submitted by participant) (300 GBP);
2 page colour presentation article in the Socrates Almanac (A4 format, 6500 symbols, layout produced and submitted by participant) (500 GBP);
Colour advert, page 2, 3 or 4 of official forum brochure (A4 format, material produced and submitted by participant) (900 GBP);
Colour advert, in body of official forum brochure (A4 format, material produced and submitted by participant) (300 GBP).
