XXXVI INTERNATIONAL NES CONGRESS

April 8 – 10, 2009

PRESIDENTE INTERCONTINENTAL Hotel, México

REGISTRATION FORM
Name
   Last name
  
Adress
Zip Code    City
State    Country
Area code

Telephone

   Fax.
E-mail

 

(Only if it is different from the above name)
Name´s receipt
Adress
Zip Code     City
State     Country
 R.F.C.     
Accompanying

 

REGISTRATION FEES                Please tick in the aplicable space X.
CATEGORY Until March 27th, 2009 During the Congress
NES members and others

$ 550.00 USD

(first night of hotel NOT INCLUDED)

$ 600.00 USD

(first night of hotel NOT INCLUDED)
Trainees

$ 275.00 USD

(first night of hotel NOT INCLUDED)

$ 300.00 USD

(first night of hotel NOT INCLUDED)
Accompanying persons

$ 250.00 USD

(first night of hotel NOT INCLUDED)

$ 300.00 USD

(first night of hotel NOT INCLUDED)

CANCELLATIONS TO THE CONGRESS:

Up to 90 days prior to arrival - full refund less bank charges

Up to 60 days prior to arrival - cancellation charge of US$ 50.00

Less than 60 days prior to arrival - no refund

PAYMENT FORM

Please tick in the applicable spaces √

Wire Transfer to B.P. Servimed, S.A. de C.V                        

        California Commerce Bank Account nbr 59461001-01

        ABA 122233645

        2029 Century Park East No. 42 P.O. Box 90067

        Los Angeles, Ca. USA 

Credit Card charge                                                                     

        Charge will be made by  B.P. Servimed, S.A. de C.V.

Credit charge in the amount of  $  

Credit card issued by                 
 Card number              Valid from Month Year

 

  

                   Thru       Month   Year

                 Card Security code  

  

Visa y M.C. a 3 digits numbers found in the back of the card.

American Express a digit number found in the center right of you card.

Name of the card holder  

By this promissory note I bind myself to the order of the issuer of my credit card.  Thjis promissory note derives from the current agreement in regard to the utilization of the credit card entered into by and between the issuer and the credit cardholder and represents the warranties effected by the signer in regards to the credit which was granted.  Both the restitution of the amount disposed likewise the interests beared by the aforecited amount so be fixed are estimated upon the form, terms and conditions agreed in the referred agreement.  This promissory note shall only be negotiable through credit institutions.

Fill in this form and mail it immediately to:  

B.P. SERVIMED, S.A. DE C.V.

Barranca del Muerto 520, Col. Alpes  01010 México D.F

Tel.:    + (52 55) 91.71.95.70

Faxes: + (52 55) 91.71.95.79 and (52 55) 56.60.19.03

Email: otoneurology@servimed.com.mx

Web page: www.internationalcongressotoneurologymexico.com