6th INTERNATIONAL CONFERENCE
ON CHILDREN'S HEALTH AND THE
ENVIRONMENT
14th16th of
November 2011, Location: Lodz, Poland
REGISTRATION FORM
Please send this form
to the Conference Secretariat: inches2011@wp.pl
Type/print
your name as it should appear on your name badge/participants list.
Family name:
.
..
.
First name:
.
.
Name of company:
.
Department:
.
.
.
Mailing address:
.
.
Postal code:
.
..
City:
.
.
.
Country:
.
..
.
Telephone:
.
.
.
Fax:
.
.
Email address:
.
.
v
Dietary requirements: no dietary requirements vegetarian
Registration fee in
Euro: 150,00
Please
transfer payment into the following account with note: INCHES Conference and
your name:
|
Bank, Location |
Bank Pekao S.A. II O/Łσdź, 270 Piotrkowska St., 90- 361 Łσdź, Poland |
|
Account holder |
Nofer Institute of Occupational Medicine |
|
Account number |
PL 46 1240 3028 1111 0000 2822 2723 |
|
Bank identification number (BIC) |
PKO PPLPW |
|
SWIFT-code |
PKO PPLPW |
You will be finally
registered as participant as soon as the registration fee had been received.
You
will be informed by email about your successful registration.
If
you required an invoice for conference fee the following information is
necessary:
Name of
company
.
Company address
.
Company VAT number
Date:
Signature: