Registration

Rates:

Early rate (payment received before February 1st 2016)	€950
Late rate (payment received before May 15th 2016)	€1100
On site rate (payment received afterMay 15th 2016)	€1400
Residents rate (accompanying letter for verification required, maximum 10 participants)	€550
Course dinner (Friday evening) including drinks	€125

Name*
First Last
Title
- Dr
- Prof Dr
Email*
Enter Email Confirm Email
Birth date*
Address*
Country
Name of the hospital where you work*
Trainee?*
- Yes
- No
Can you upload a proof that you are a trainee now? If you don't have this now, please email it to us later as a reply on the confirmation email you will receive.
Accepted file types: jpg, gif, png.
Specialisation*
- ENT specialist
- Maxillofacial surgeon
- Plastic surgeon
How many rhinoplasties have you performed yet?
Passport size picture
Accepted file types: jpg, gif, png.
With how many people would you like to participate in the course dinner?
Registration fees are as follows:
We kindly request to transfer below mentioned amount within 2 weeks to
Guesthouse B BVBA
IBAN: BE67 0017 7822 2487
BIC: GEBABEBB
Memo: Name participant + Antwerp rhinoplasty course
Phone
This field is for validation purposes and should be left unchanged.