Registration Form - Advanced MSUS Course Tielt

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Registration Form - Advanced MSUS Course Tielt - 25 & 26 May 2024

Dear,

Thank you for your interest in our course. Would you like to participate ?

Please complete the registration form and make payment of the course fee to the Benetec bank account.

Email *

Last Name *

First Name *

Discipline *

Radiology

Physical Medicine

Sports Medicine

Other:

Hospital or Practice *

RIZIV N° or Registration N° (for accreditation) / or NA *

Billing Address

Please enter the correct invoicing details. This can be the address of your private practice or the hospital where you work. For invoicing to hospitals, an order form from the hospital is needed.

Billing Name / Company Name *

Street & Number *

ZIP Code & City *

Country *

VAT N° or Company N° (if applicable) / or NA *

e-mail address *

Phone N° (with country code) *

I agree that Benetec BV uses my details to send information about future courses, congresses or new products. *

YES

Thank you for your subscription. In order to be officially registered for the course, please transfer the course fee of 1.120 EUR (incl. VAT) as follows :

To : Benetec BV

IBAN : BE 080 688946587 13

SWIFT/BIC : GKCCBEBB

Reference : MSUS Course May 2024 + your name

Once we have reveiced your payment, we will add you on the attendance list and prepare your invoice.

If any other questions please mail to academy@benetecmed.com

A copy of your responses will be emailed to the address you provided.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms