Registration Form

12^th International Course in Modern Rhinoplasty Techniques
and Facial Plastic Surgery

Jun 8-10, 2006

Download

("regform12.rtf" Rich Text Format)

University of Pécs Faculty of Medicine

Department of Otorhinolaryngology, Head and Neck Surgery

Registration Form

Name: ________________________________________________________

Institute: ______________________________________________________

Address: ______________________________________________________

City: _________________________________________________________

Country: ______________________________________________________

ZIP code: _____________________________________________________

Phone: _______________________________________________________

Fax: _________________________________________________________

E-mail: _______________________________________________________

On-site registration fee (please check one of the options):

( ) EUR 600 - with dissection

( ) EUR 400 - without dissection

Please sent the completed registration form by mail or fax to:

Attn. Rita Boros

Address: University of Pécs, Faculty of Medicine

Department of Otorhinolaryngology, Head and Neck Surgery

Munkácsy M. u. 2.

Pécs, Hungary

H-7621

Phone/Fax: +36 72 312-151