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Registration Form (One form per active participant) Please note that you may also register online: www.ocularinfections.com Prof. Dr. Please return before February 21, 2013 Family Name (please underline) / First Name, Initials Clinic Hospital Institute Company: Department Speciality Street, No P.O. Box Postal Code / Zip Code City Country State / County (where applicable) E-mail Work Telephone Home Telephone Fax Registration Fees (per person) Prior to December 22, 2012 December 23, 2012 until February 21, 2013 On Site Amount Full Participant 600 USD 720 USD 860 USD Daily Rate for Locals 270 USD 7.3.13 9.3.13 8.3.13 10.3.13 325 USD 7.3.13 9.3.13 8.3.13 10.3.13 390 USD 7.3.13 9.3.13 8.3.13 10.3.13 PAAO Member 540 USD 650 USD 775 USD Student* 350 USD 420 USD 500 USD Residents** 60 USD 60 USD 60 USD Accompanying Guests 65 USD Gala Dinner 150 USD Total Fees $ * Students must provide "proof of student" (transcript, copy of student identification card, or letter signed by head of department) ** The rate refers to residents from the following universities: UCLA; UCSD; UCSF; University of Southern California The total amount will be paid as follows: Please debit my card for the total amount due Credit Card: Visa MasterCard American Express Diners No. Date of expiration CVV2 Code Name as shown on Card: _____________________________________ Passport No. ______________________________________________ I have transferred the total amount due and attach a copy of the bank transfer details and have ensured that I have paid for all charges. Bank detail: ICOI 2013, Account No. 0240-459284.19Z, IBAN code: CH830024024045928419Z, SWIFT code: UBSWCHZH80A, Currency USD. Bank charges are the responsibility of the costumer and should be paid at source in addition to the registration fees. Payment via bank transfer is subject to receipt of confirmation from the bank. The charge via credit card/ bank transfer will be made in US Dollars. Bank transfers should be made no later than February 21, 2013. Cancellation Policy Refund of Registration Fees will be made as follows: Up to 90 days prior to arrival-full refund less bank charges ** Up to 60 days prior to arrival-cancellation charge of 50 USD ** Less than 60 days prior to arrival-no refund Comments: ________________________________________________________________________________________________________________ Date: _________________________________ Signature: __________________________ ICOI 2013 c/o Paragon Conventions 18, Avenue Louis-Casai 5th floor 1209 Geneva, Switzerland Fax: +41 22 5802953 Email: [email protected]
