Deutsches Herzzentrum - Online registration

Focus on congential cardiac surgery

4th International Combined Live Symposium by
Deutsches Herzzentrum München, Germany
Herzzentrum Leipzig, Germany
Great Ormond Street Hospital London, UK
December 14-15, 2006

Please fill out (1) registration form per attendee
fields marked with an asterisk (*) are required fields.


* Last Name:		* First Name:
Title:		Institution:
Department:
* Address:
* Area Code:		* City:
* Country:		Email:
* Phone:		Fax:

	Thursday & Friday	(€600)
	only Friday	(€500)

Friday evening "get together"
	Yes, I will attend
	Yes, my guest will attend
	Guest Name: (€90)

	Registration fees should be paid as bank transfers to Hypo Vereinsbank BLZ: 700 202 70 Account Nr.: 660 947 175 SWIFT (BIC): HYV EDE MM XXX IBAN: DE38 7002 0270 0660 9471 75


Signature: (for those faxing form)