mr
ms
prof
pd
dr
*
family name
*
first name
*
hospital, institute, company
department
*
street, number
p.o.box
*
postal code, zip code
*
city
state, county (where applicable)
*
country
telephone business
telephone home
fax
*
email
*
Please register me
Active Participant
€ 290
Stud/Phys in Training
€ 150
Additonal option:
CMR Exam (Sat pm) for
€ 125
*
I accept the Terms & Conditions
*
Payment Options
I will pay by bank transfer
(receipt will be sent by email to confirm the payment)
I will pay at the reception desk
(cash only, no credit cards)
I want to pay online by credit card
(You will be taken to the secure checkout after pressing the 'Register'-button).
(
*
required fields
)
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