The Third International Congress of Maritime, Tropical, Hyperbaric

The Third International Congress of Maritime, Tropical,
Hyperbaric and Trawel Medicine 2015
20-24 May 2015
Application for participation
Name and Surname
Address
Date of Birth
Phone number
E-MAIL
Name and Surname
accompanying person
Address
Date of Birth
Invoice
Name Company
Address
TAX Number
Congress Fee
Copenhagen-Oslo-Copenhagen
Please tick the
appropriate box
Registration for
31.03.2015
Congress Participant ( cabin without window)
540 EUR
Accompanying Person ( cabin without window)
480 EUR
Congress Participant ( cabin with a window)
560 EUR
Accompanying Person ( cabin with a window)
495 EUR
Supplement to the 1-person cabin
Please tick the appropriate box
Registration for
31.03.2015
Cabin with a window
240 EUR
Cabin without window
190 EUR
Supplement to the route Gdynia-Copenhagen-Oslo-Gdynia 100 EUR
Fees should be paid to the account of the Organising Office:
MCC Consulting Sp. z o.o., ul. Jeżynowa 7, 96-300 Żyrardów, Poland
BANK BPH SA account details:
SWIFT: BPHKPLPK
IBAN: PL 92 1060 0076 0000 3200 0131 6600,
Transfer description should contain the name and the surname of the participant, and the title
“III Congress”.
I declare that, my health allows me to participate in the trip, in case of illness during the trip I
release the doctors treating me with the duty of medical confidentiality with respect to the Insurer,
and I authorize the release of his medical records. I also declare that I have read the terms of medical expenses and accidents contained in the
General Conditions of Insurance Signal Iduna.
Application for participation please send by fax to number +48 46 856 30 13 or by
e-mail to office@mcc.org.pl
........................................................
Date and Signature