REGISTRATION FORM IV. Symposium on Scoliosis and Spinal Deformities Wednesday 23rd – Friday 25th April 2014 Name * Surname * Profession Hospital/Institution * Address * Country * Phone E-mail * Additional Information I am intertested in attending the symposium: only on Wednesday 23.4.2014 - EUR 4 only on Thursday 24.4.2014 - EUR 30         (I am a doctor) only on Thursday 24.4.2014 - EUR 19         (I am a nurse or a student) on Thursday and Friday 24.-25.4.2014 - EUR 48         (I am a doctor) on Thursday and Friday 24.-25.4.2014 - EUR 30         (I am a nurse or a student) I am intertested in: dinner on Thursday 24.4.2014 - EUR 25 Total Fee Please send the total registration fee to this bank account Bank details: UniCredit Bank Czech Republic, a.s., Address: Želetavská 1525/1, 140 92 Praha 4 Bank account Nr.: 515293009/2700 IBAN: CZ26 2700 0000 0005 1529 3009 SWIFT: BACXCZPP Please include note with your name.           Copyright © 2014 Aesculap Akademie