Online registration

Surname * First name *
Address * Zip code *
City * Country *
Telephone * Cellphone
E-mail *

I am a NVEPC member
I am a trainee
No, I am not a member nor a trainee

	Members NVEPC	Trainees	Non-members
Friday 9 and saturday 10 december	€ 575,-	€ 350,-	€ 750,-
Only saturday 10 december	€ 200,-	€ 50,-	€ 250,-

Yes, I will join for the evening program on friday (no extra charge)
Yes, I will join for the partner program on saturday (incl. lunch) € 60,-

I am fully aware of the costs involved. I will transfer the course fee within 1 weeks after this form is send. Preregistration is accepted with a payment before 19 November 2011. I will add 50 euro’s for registration after 19 november.

For questions and memberships of the NVEPC please send an mail to the office of the NVEPC: b.sopacuaroelofsen@umcutrecht.nl

CAUTION! Before clicking 'SUBMIT' make sure you have filled in every tickbox. After correctly submitting your form, a confirmation-screen will pop up and a confirmation email will be send to your email-address.