Registration

Please fill the following form:

 Civility*:
 Name*:
 Firstname*:
 Type of practice*:
 Type of facility:
 Email*:
 Confirm your Email*:
 Principal address:
 Address type:
 Postal code:
 City:
 State:
 Country:
 Phone*:Country code:  Area code:  Phone:
 Mobile phone:Country code:  Area code:  Phone:
 Fax:Country code:  Area code:  Phone:
 Message:
 Billing address: Different from my principal address?
-  Billing address:
-  Billing address type:
-  Billing postal code:
-  Billing city:
-  Billing state:
-  Billing country:
 Registration fee*:140.00 € (Pharmaceutical industry)
80.00 € (Investigator/Physician/Professor)
0.00 € (Student/Resident/Young investigator)

Important information: Your inscription will be confirmed as soon we will have received your full payment

Reduced fees (Student/Resident/Young investigator) will be applicable only with certification to be sent by fax
(+33 1 70 24 85 28).
 Mode of payment*:Credit card (VISA, Mastercard, ...)   Bank transfer   Bank check (for France)
Bank name: LCL /Issy les Mx Corentin
Code banque : 30002 - Code agence : 00516 - Compte N° : 0000007473U - Clé RIB : 23
IBAN : FR73 3000 2005 1600 0000 7473 U23 - SWIFT : CRLYFRPP
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* Mandatory fields
PremUp foundation, Paris 6ème, authorized ORIGINES CONSEIL EN COMMUNICATION SAS company (TVA FR 38481385045) to receive inscription fee for symposium and to organise the event.