http://www.eortc.be
http://www.eortc.be/probe

REGISTRATION FORM

EORTC Course on
Quality of Life, Symptom Research and Patient Reported
Outcomes in Cancer Clinical Trials

To see the program, please click here

As the number of places on this course is limited, participants are encouraged to register as soon as possible.
The registration is free for academics but registration is mandatory to attend.
Registration (and corresponding payment for industry representatives) should be received before November 10, 2009.
Confirmation of your participation will be sent only upon receipt of complete registration data (and payment for industry representatives)
TITLE Prof. Dr. Ms. Mrs Mr.
LAST NAME
FIRST NAME
INSTITUTION / COMPANY
DEPARTMENT
SPECIALITY / FUNCTION
ADDRESS
POSTCODE TOWN / CITY
COUNTRY
PHONE FAX
E-MAIL
NATIONALITY
GENDER

Male

 
AGE (years)  
WHERE DID YOU HEAR ABOUT
THIS COURSE		  
ESMO (member ID Code)  

 

INDUSTRY REPRESENTATIVES

The registration fee for the course has to be paid by wire transfer and is
- 700 Euros for payment received before 1st August 2009 (early rate)
- 800 Euros for payment received between 1st August 2009 and 1st October 2009 (late rate)
- EORTC has applied for ESMO-MORA points Category 1 accreditation, permitting ESMO members a 25% reduction on registration fee
The VAT is included within the registration fee.

Deadline for registration (and payment for industry) is November 10, 2009

BANK DETAILS
Fortis Bank SA, 14 Ave de l'Astronomie, 1210 Brussels, Belgium
Account No. 210-0510010-36
IBAN BE46 2100 5100 1036
BIC/SWIFT GEBABEBB
Communication: "Registration Course QOL Probe 2009 + name of participant"

CANCELLATION POLICY
Cancellation of registration has to be faxed or e-mailed to the EORTC Quality of Life Department.
For industry representatives:
- If under 2 months’ notice of cancellation is given, 50% of the registration fee will be retained
- If under 1 months’ notice of cancellation is given, no refund will be paid.
Refunds will be processed by bank transfer after the course.

 

For further information, please contact:
Ms. Irina GHISLAIN, EORTC Quality of Life Department
Avenue E. Mounier, 83, Bte 11 • 1200 Brussels, Belgium
Phone: +32 2 774 10 57 • Fax: +32 2 779 45 68 • E-mail: irina.ghislain@eortc.be