REGISTRATION FORM Symposium on Comparative Pathology 2003

14^TH LJUDEVIT JURAK INTERNATIONAL SYMPOSIUM ON COMPARATIVE PATHOLOGY
Main topic: Dermatopathology
June 6-7, 2003 - MULTIMEDIAL CENTER, UNIVERSITY HOSPITAL "SISTERS OF CHARITY", ZAGREB, CROATIA

REGISTRATION FORM
Please type or print in block letters
Please print this form and send by fax or post

Prof, Dr, Mr, Mrs: Family Name: First Name:

Institution:Address:

Postal Code: City: Country:

Phone: Fax: E-mail:

Accompanying Person(s) 1. Family Name: First Name:

2. Family Name: First Name:

Registration Fees

Participants 800 kn - 100 EUR (before April 1, 2003)
1200 kn - 150 EUR (after April 1, 2003)

Accompanyng Person 250 kn - 30 EUR

Slide Seminar 400 kn - 50 EUR

Total payment:

Methods of payments

By Credit Card: Diners Club American Express VISA MasterCard/EuroCard

Card number: Expiration date:
Card holder's name:

Signature: __________________________________ Date:
(Autorized signature of cardholder)

By bank transfer in favour of Croatian Academy of Medical Sciences, 10000 Zagreb, Šubićeva 29, Croatia
Account number (for kunas) at Zagrebačka banka d.d: 2360000-1101481831
Account number (for EUR) at Privredna banka d.d: 70300-978-9182800-137182
Account name (Swift): LJJ/2003

On site payment in cach only

Please indicate participant’s name on the transfer.
Print and send by mail above form together with copy of your bank transfer to:

Ljudevit Jurak University Department of Pathology
Sestre Milosrdnice University Hospital
Vinogradska 29
10000 Zagreb - Croatia

Phone: +385 1 37 87 909 w Phone/fax: +385 1 37 87 244
juraks@kbsm.hr

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Postal Code:	City:	Country:
Phone:	Fax:	E-mail:
Accompanying Person(s)	1. Family Name:	First Name:
	2. Family Name:	First Name:
Registration Fees
Participants	800 kn - 100 EUR (before April 1, 2003) 1200 kn - 150 EUR (after April 1, 2003)
Accompanyng Person	250 kn - 30 EUR
Slide Seminar	400 kn - 50 EUR
Total payment:
Methods of payments
By Credit Card: Diners Club American Express VISA MasterCard/EuroCard
Card number: Expiration date: Card holder's name:
Signature: __________________________________ Date: *(Autorized signature of cardholder)*
By bank transfer in favour of Croatian Academy of Medical Sciences, 10000 Zagreb, Šubićeva 29, Croatia Account number (for kunas) at Zagrebačka banka d.d: 2360000-1101481831 Account number (for EUR) at Privredna banka d.d: 70300-978-9182800-137182 Account name (Swift): LJJ/2003
On site payment in cach only