WPA Regional Congress 2010

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WPA REGIONAL MEETING Saint-Petersburg, Russia, June 10-12, 2010

REGISTRATION FORM

PLEASE COMPILE THE FORM AND SEND IT BACK TO: info@altaastra.com or by fax: +7-812-717-67-47

>> HOTEL ACCOMODATION FORM
>> EXCURSIONS PROGRAM
>> REGISTRATION FEE (IN EURO)

Please fill the form in BLOCK LETTERS

Family Name

First Name

Place of work*:

Organization/Company *:

Mailing Address: Postal Code

City

Country

Phone

Fax

E-mail :

Accompanying Persons:

Family Name

First Name

If Child, Age

Family Name

First Name

If Child, Age

The Organizing Committee reminds you that in case of visa support necessity please fill application form (on the web-site: www.wpa2010spb.com), and send it with the copy of your passport to: info@altaastra.com or by fax: +7-812-717-67-47

*Please register me as:**			Psychiatrists and other physicians
			Trainees
			Students**
			Accompanying persons
			Workshop (Course)***
Please book the invitation for: (Tickets are limited)			Gala dinner (per person) 100 EUR

*See list of the countries at the web-site of the conference (www.wpa2010spb.com)
**Please attach the copy of the student card or a certificate by the chairperson of the Department
*** Registration for Workshop (course) is only available to participants registered for the Meeting:
*Michael Musalek "Humanistic aspects pf psychiatric practice"

NB! Your registration fee depends on the payment period � see the web-site (www.wpa2010spb.com)
All cancellations must be addressed to the Organizing Secretariat. 100% of the deposit will be refunded for cancellations marked by April,15, 2010; no refund will be made for cancellations postmarked after April 15, 2010

PAYMENT SUMMARY

Registration Fee		Euro
Hotel Accomodation		Euro
Excursions program		Euro
Visa support		Euro
TOTAL

Please, send me the Invoice according to the set of service booked. Please fill this form:

Institution (or the name of the person)

Address

Postal Code

City

Country

VAT number

I will pay with my credit card:

			Visa
			Master Card
			Maestro
			American Express
(For payments by credit card, please enclose the photocopy of the card (front and back).

Card number

Expiration Date (month/year)

Cardholder�s Name

Cardholder�s Signature

Please enclose the phrase:� I allow to withdraw the money from my credit card			in the sum of
After withdrawal of the money � you will get the confirmation and the receipt.

I will pay by bank transfer to: �SEB Bank� Saint Petersburg, Russia,195009, Mikhailova str.11
Corr./account 30101810500000000747, BIK 044030747; Account 40702978100000000215 SWIFT: SEBPRU2P

ADDRESS OF THE ORGANIZING COMMITTEE:
194044, St.Petersburg, Russia, Pirogovskaya emb. 5/2, lit A-A1
tel/fax: +7-812-717-67-47, 717-35-56
E-mail: info@altaastra.com://www.altaastra.com

Registration

Hotel reservation

Abstract submision