Registration Form

                                                                                                                                                            

 

 

 

 

 

Save a PDF copy

 

Please fill the Registration Form

 

First Name:
Family Name:
Profession / Title:
Affiliation:
Mailing Address:
City:
Country:
Residence Phone:
Clinic Phone:

Fax:

Mobile:

E-mail:
I Will Present a paper:

Accompanying Persons:

 

Mr. Mrs.

Mr. Mrs.

 

 

 

Please select your Registration Fees:

 

 

 

  

   Members of WFMH

                              USD  350

   Non Members of WFMH

                              USD  450

   Citizens of Developing Countries

                              USD  250

   Consumers / Family Members

                              USD  250

   Accompanying Persons

                              USD  150

   Students (Full Time)

                              USD  100

   One Day Registration for Locals

                              USD    70

For Those Booking Hotels Outside the Congress Group, Add 50 USD

 
Payment

1)  I enclose with this form :
     Photo copy of bank transfer
     in the amount of 

 

2) Credit Card Payment method:

Press here to print Credit card form and fill it then scan the form after signature and send it via e-mail to us:

         

Or Send by E-Mail:   info@wfmh2005.com