6th Middle East Congress on Rhinology & Facial Plastic Surgery

6th Middle East Congress on Rhinology & Facial Plastic Surgery
MERC2016 Registration Form

April 13-15, 2016

Dear Colleagues:
Please fill this form for MERC2016 registration. Please note that at this time, online payment is not available for the congress fee payment. So you can transfer the congress fee to the bank account according to the table below and fill the payment field with the wire transfer information. Registration will be confirmed when the payment is verified by congress secretariat.

Registration Fees (in Euro):

	Early Registration Before February 20, 2016	Late Registration Before March 20, 2016	On Site Registration April 13, 2015
Physicians	290 €	390 €	490 €
Residents	190 €	260 €	340 €
Accompanying Person	65 €	95 €	125 €
Exhibitors	65 €	95 €	125 €

Pre-Congress Workshop Registration Fee (in Euro):

	Before April 12, 2016
All Participants	195 €

Personal Information

Title *

Please select title

First Name *

Please fill First Name

Middle Name

Please fill Middle name

Last Name *

Please fill Last Name

Name on Badge

Invalid Input

Country *

Fill your Country

City *

Fill your City

Address *

Fill your Address

Phone *

Invalid Input

Fax

Invalid Input

Cell Phone

Invalid Input

Email Address *

Insert a valid email address

Congress Registration Details

Registration Type *

Please select registration type

Number of Accompanying Person(s)

Invalid Input

Accompanying Person(s)

Invalid Input

I want also register for pre-congress workshop - 195 Euro

Payment Information

Total Fees

0 Euro

Payment Status *

Please select your payment status

Please fill here with your payment details and send your payment receipt by fax or email. Please NOTE that the registration remains pending until the payment will be approved.

Payment Details

Invalid Input

Please pay the total fees to the following account and send the receipt by fax or email. Please NOTE that the registration remains pending until the payment will be approved.

Account Details for Payments:
OUR BANK IS LOCATED IN GERMANY
Please advise the beneficiary by SWIFT for EUR payments)

IBAN : DE22 3804 0007 0304 9699 00
BIC : COBADEFFXXX
NAME OF BANK: CCOMMERZBANK
Account Holder: Masoud Boroojerdi