REGISTRATION FORM

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REGISTRATION FORM

Program: https://tinyurl.com/2rhfsm6w

Clinical Site no.

See List of Members available here

Name and Surname *

Email *

Phone

Scientific Sections participation

Thursday, 19th October 2023 @ 16:15

Retina

Anterior Segment

Attending dinner? *

Thursday, 19th October 2023 @ 20:00

Yes

Registration Fee *

(including materials, coffee breaks and dinner)

Before 30th September 2023 - 200 €

After 1st October 2023 - 250 €

Early Career Investigators - 100 € - A discount is available for trainees who are currently in a residence program. Please download the Trainee Verification Form (https://tinyurl.com/3d6vysjx), fill and sign and send by email to lfseco@aibili.pt.

Payment *

Registrations will only be valid with payment. Please send evidence to lfseco@aibili.pt

Bank transfer: Banco Português Investimento - Alameda Armando 3000-059 Coimbra, Portugal; IBAN: PT50 0010 0000 4441 5990 0016 7 BIC/SWIFT: BBPIPTPL

Cheque: payable to EVICR.net and send it to: EVICR.net, AIBILI - Azinhaga de Santa Comba - Celas, 3000-548 Coimbra, Portugal

Receipt will be issued to the Clinical Site. If different please provide information below.

Name

Complete Address

VAT Number

Cancellation

No reimbursement of registration fee shall be made.

How to reach the Meeting Venue and Accommodation: https://tinyurl.com/4fzwf777

Meeting Sponsor

We are collecting your personal data in order to register you for the 18th Members Meeting. Consult our Privacy Policy available at http://www.evicr.net/privacy.php *

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I understand that my personal data will be used to send me information relating to EVICR.net.

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Thank you for your registration!

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