Registration with abstract or you are a trial coordinator/ study nurse

Registration is accepted according to the 'first come, first served' principle.
For participants who have also submitted an abstract (to maaike@bureau-prevents.nl) to be discussed during the conference,
or you are a trail coordinator/study nurse a reduced rate of 162.50 euros applies. If not, click here.

Participation is only possible for the two days.
Hotel stay must be arranged by participants.

Gender:		Mrs.     Mr.
Title:
Name/Initials:
Prefix:
Surname:
Country:
Phone number (+country code):
E-mail address:
Specialism:
You are:		physician fellow in training
Hospital:
City:
Country:
BIG code:
Payment method:		Electronic banking (iDeal, MasterCard, Visa, American Express, Pay Pal and more)   (this is the only payment method)
		Debit (SEPA, Single Euro Payments Area)
Ascription:  Address:  Postal code:  City:  Country:  IBAN number:    You can enter your IBAN number above. BIC code:        Select a bank for your BIC code. If unavailable you need to bring your complete BIC code.
Permission required due to General Data Protection Regulation (GDPR) Agree that we process your data in accordance with our Privacy Statement and Sponsor Policy. It is mandatory to fill in this box: otherwise we will unfortunately not be able to register you.
Question (optional):
(Fields that are marked with a   are mandatory fields)