Spoedgevallen campus Sint-Jan
050 45 20 00
Spoedgevallen campus Henri Serruys
059 55 51 01
EBTA2016 >  Registration

Registration

In case this form isn't working properly, please contact stefanie.vanpachtenbeke@azsintjan.be.

With this form you can send an application for registration to the organizers.
You will be registered when you receive a confirmation.


General information*"

Saluation
Name
First name
Language
Payment by

Professional information

Firm/Company**
Work street**
Work postal code**
Work city**
Work country**
 
Work account number
Work BIC
Work IBAN
 
Work e-mail**
Work phone**
Work mobile
Work fax

Personal information

Private street***
Private postal code***
Private city***
Private country***
 
Private account number
Private BIC
Private IBAN
 
Private e-mail***
Private phone***
Private mobile

Choose your activities*

- Time: 22/09/2016 13:00 until 22/09/2016 17:30
- Places available: 73 out of
- Time: 22/09/2016 19:00 until 22/09/2016 22:00
- Places available: 175 out of
- Time: 23/09/2016 10:00 until 23/09/2016 23:55
- Places available: 98 out of
- Time: 23/09/2016 10:00 until 25/09/2016 16:00
- Places available: 245 out of
- Time: 24/09/2016 19:00 until 24/09/2016 19:01
- Places available: 149 out of
- Time: 26/09/2016 10:00 until 26/09/2016 17:00
- Places available: 83 out of

Comments


* required field
** required field in case of firm/company
*** requried field in case of private person

Submit