Please fill out this form online and press the 'Submit' button, or PRINT, fill out in BLOCK LETTERS and FAX or AIRMAIL together with your payment, to Secretariat's address:

INTERNATIONAL ACADEMY OF CARDIOLOGY
15th WORLD CONGRESS ON HEART DISEASE
ANNUAL SCIENTIFIC SESSIONS 2010


PO Box 17659, Beverly Hills, CA 90209, USA
Tel: +1 310 657 8777
Fax: +1 310 659 4781

Participant's Identification
Please complete this section accurately. The information you provide will allow us to correspond with you efficiently.

Fields marked with (*) are required.

Surname/Family name:(*)
First name and middle initials:(*)
Title:
Institution:
Dept.:
Address:(*)
City:(*)
Zip Code:(*)
State/Province:
Country:(*)
E-mail:(*)
Telephone:(*)
Country Code/city code/number
 
   Extension
Fax:
Country Code/city code/number

Registration Fees
Please check the appropriate box/s:

  after
July 21, 2010
Participant US$ 720
Nurse, Technician, Trainee*, Student** US$ 595
Farewell Dinner (optional)

number of Farewell Dinners:

US$ 95
Get-Together Reception cost for Accompanying Person(s)

number of Get-Together Reception  

US$ 45

Total Fees  

* letter of verification required
** valid student card required

Fees for PARTICIPANTS include: participation in all scientific sessions, Congress kit, program, abstract book, printed material of the Congress and invitation to Get-Together Reception.

The Social Program for all participants is:

Saturday, July 24, 2010 at 18:30 Get Together Reception
Cost for Accompanying Person is US$ 45


Monday, July 26, 2010 at 20:00 Farewell Dinner (optional)
Cost is US$ 95


You can purchase these tickets upon your arrival at the Congress Registration Desk.
For information and booking of tours, you will be able to contact the hotel front desk all times.

Payment
Please indicate the amount enclosed and preferred mode of payment.
Please ensure that you send your fully completed Registration form together with your payment:

Option 1:
Credit Card - Payments will be charged in US$ according to the rate of exchange to the Euro on date of payment.
Please note that you must fill out all the boxes under this section if you are paying online by credit card.

Credit card type: American Express Visa MasterCard Diners
Number:
Expiry Date (month/year):
CVV Code (security code)
(for Visa/Mastercard last 3 digits on back of card
for American Express, 4 digit code on front of card
 
Cardholder name or Company
Credit Card Billing Address  
Address:
City:
Zip Code:
State/Province
Country:
Credit Card Contact Phone Number:
Family name:
First name:
Signature
printed form only
__________________________
Date (day/month/year)
printed form only
__________________________
   

Option 2:
Bank Transfer -For further information regarding a bank transfer, please contact the Secretariat.

Option 3: (with printed form only) 
Cheque made payable to: International Academy of Cardiology
Enclosed cheque number: _______________ Bank: _______________________________
Please include fully completed registration form.

 

 

CANCELLATION POLICY
50% refund on registration fees is applicable if written cancellation received before May 11.
25% refund on registration fees is applicable if written cancellation received before July 10
After July 10 no refund available.


Date: ____________ Signature: ____________