REGISTRATION FORM

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Personal Information

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Last name*

First name*

Mobile phone

E-mail

Date of birth*

City of birth*

CF/SSN
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SSN

Residence Information

Address*

City*

Zip code*

Country*

Provincia Only for Italy

Professional Information

Profession*

Specialty*

Hospital/Company/University

Department

Congress Registration

done	Physician	1.200€
done	Industry	600€

Billing information

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First name Last Name / Company Name

Address

City

Zip code

Country

VAT Number / Fiscal code

SDI (Only for italian)

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Processing of personal data

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