REGISTRATION FORM

Please print this form and send or fax the completed form to:

Conference Secretariat ICCHE ´07

c/o Julia Hellmann

Department of Public Health, Medical Decision Making and Health Technology Assessment

UMIT – University for Health Sciences, Medical Informatics and Technology

Eduard Wallnoefer – Zentrum I

A-6060 Hall in Tirol

Austria, Europe

Phone: +43 - 50 – 8648 – 3878

Fax: +43 - 50 – 8648 – 67 - 3878

E-mail address: inches@umit.at

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 number

Telefax number

Email address

Registration fee in Euro:

Paid before 1^st of May 2007: € 300,-

Paid after 1^st of May 2007: € 360,-

Student (with approval from the university): € 100,-

Sponsored participant from developing countries on request: € 50,-

Dinner reception on Saturday 9^th of June 2007 per person: € 40,-

Vienna concert & museum night per person: € 35,-

Payment in Euro will be made to:

[ ] By bank transfer to Raiffeisen-Landesbank Tirol, BLZ: 36000, account number: 100.686.428

account holder: Institut für Medizinische Informatik und Technik Tirol GmbH - “INCHES Tagung”

International Bank account number:

Swiftcode: RZTIAT22 IBAN: AT 93 36000 00100686428

[ ] For Holders of MasterCard or VisaCard:

Please insert:

card number (16-digit):

expiration date:

amount: Euro

CVC (the last three numbers on the back of your card):

These data will be sent to the institute of Mastercard or Visacard by the INCHES secretariat.

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.

Date : Signature: