HEALTH OPTIMUM :: Registration Form

Registration Form

Last Name (*)
First Name (*)
Institution/Company/Organization (*)
Department
Address (*)
City (*)
Country
Postal/Zip code
Telephone (*)
Mobile
E-mail (*)
Fax
Participation to the city tour (Wednesday 3rd June p.m.) euro 25,00
Participation to the gala dinner (Wednesday 3rd June p.m.) euro 50,00
Under the terms of Italian Statute no. 196 of 30/6/2003, wich protects the privacy of personal data, we would inform you that the personal data supplied through this site will be used only for communications regarding the meeting organization. You are entitled to call for the cancellation or correction of data in our possession at any time. We also confirm that the said data will not be disclosed to third parties.
I hereby declare that I carefully read the privacy policy and I fully give my consent (*)
insert the result: 98+14 =
(*) MANDATORY