The invitation is under restriction of the VISA number
PERSONAL INFORMATION
Gender * :	Female Male
First name * :
Last name * :
Date of birth * :
Hospital * :
Email * :
Mobile phone * :
Job title * :
ID-card N° * :
ID Expiry date * :
Nationality * :	Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo (Brazzaville) Congo (Kinshasa) Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong S.A.R., China Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Ivory Coast Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao S.A.R., China Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Outlying Oceania Pakistan Palau Palestinian Territory Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia And Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu U.S. Virgin Islands Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican Venezuela Vietnam Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe
MEALS
I will join the following dinners
Tuesday 11/3 * :	Yes No
Wednesday 12/3 * :	Yes No
Thursday 13/3 * :	Yes No
Dietary requirements or allergies :
* From 2017, pharmaceutical companies are required to publish any contribution to a conference participation or to an other scientific event on an individual and nominative manner on the website www.betransparant.be. More info can be found on this website. In order to publish correct information, please fill in the fields below.
INFORMATION FOR BETRANSPARANT*
RIZIV/INAMI number * :
and
Identification number of the National Register (Rijksregisternummer/numéro d'identification) * :
ADDITIONAL INFORMATION
Member of the congress organisation * :	Yes No
Membership number :
To be in accordance with the legislation for participants to congresses, the pharma industry is held to make a fiscal declaration. Therefore, please select one of the possibilities below:
* :	Employee at a hospital/care institution Self employed - privately Self employed - company (bvba, sprl, ...)
If you've chosen 'Employee at a hospital/care institution', please give the address of the hospital
If you've chosen 'Self Employed - Privately', please give the address of your company
If you've chosen 'Self Employed - Company', please give the address of your company
Name * :
Street + nr * :
City * :
Postal code * :
Company identification number (only in case of a company) :
E-mail address of the accounting department of your company or hospital (to send the tax form)
E-mail * :
CANCELLATION
In case of cancellation, we ask you to notify us as soon as possible by e-mail. We will do the utmost to ensure that the terms of cancellation are as favorable as possible, tough if unforseen costs should arise, we will be obliged to charge you for it.
I agree * :
DATA PRIVACY STATEMENT
I have read the privacy statement * :
	(*) Input required!