1. REGISTRATION FORM, Florence November 3-5, 2016 Please complete the form using block letters LAST NAME_________________________________________________________________________________ FIRST NAME________________________________________________________________________________ ADDRESS___________________________________________________________________________________ _____________________________________________________________________________________________ PHONE_____________________________________________________________________________________ MOBILE PHONE ____________________________________________________________________________ EMAIL_______________________________________________________________________________________ Date and place of birth (mandatory)_______ __________________________________________________ TAX CODE (mandatory for Italian participants only)_________________________________________________________________________ PROFESSION_______________________________________________________________________________ SPECIALIZATION___________________________________________________________________________ INVOICING ADDRESS: Fiscal/Vat code (mandatory for travel agency/company) Please head invoice to ______________________________________________________________________ _______ ____________________________________________________________________________________________ ______________________________________________________________________ _________ DECLARATION: Your signature is mandatory in order to process your registrations and hotel accommodation. According to Art.13 Law 196/2003 Eleven Conference is authorized to use my personal data for purposes connected to he Conference management. I also confirm that I have understood the cancellation and refund policy for registration Date (DD/MM/YYYY) ____________________Signature (mandatory)_________________________ REGISTRATION FORM, Florence November 3-5, 2016 Please complete the form using block letters The registration form should be sent to: info@elevenconference.it DOCTOR RESIDENT PAYMENT ESUR Member SIRM Member SIEUN – SIU Member NON-Member by bank transfer ESR and EAU Institutional and Associate Member Societies Please specify the Member Society _______________________________________________________________ by credit card via Paypal LAST NAME/FIRST NAME ADDRESS PHONEMOBILE PHONE email Date and place of birt (mandatory) TAX CODE (mandatory for Italian participants only) PROFESSIONSPECIALIZATION INVOICING ADDRESS: Fiscal/VAT code (mandatory for travel agency/company) DECLARATION: Your signature is mandatory in order to process your registrations and hotel accommodation. According to Art.13 Law 196/2003 Eleven Conference is authorized to use my personal data for purposes connected to he Conference management. I also confirm that I have understood the cancellation and refund policy for registration Date (DD/MM/YYYY) ________________________Signature (mandatory)_________________________________________________