BINDING APPLICATION

Surname
Forname
Title
Institution
Department
Street
Town
Country
Postcode
Telephone no.
Fax no.
E-mail

Registration fees	by 28 February 2011	after 28 February 2011
doctor – member of the CSOT	€ 50	€ 70
doctor – non-member	€ 60	€ 80
nurse	€ 40	€ 60
student *	€ 0	€ 0
registration fee – 1 day	€ 30	€ 30
Participation:	active	passive

Order for accommodation
Date of arrival -------- 7 April 2011 8 April 2011
Date of departure -------- 8 April 2011 9 April 2011
Hotel Voroněž I, Křížkovského 47, Brno
single room - € 95 / person / night
double room - € 120 / 2 persons / night
Hotel Voroněž II, Křížkovského 49, Brno
single room - € 75 / person / night
double room - € 95 / 2 persons / night
triple room - € 115 / 3 persons / night
I would like to share a room with: and
Order for lunch: 8.4.2011 (€ 12) 9.4.2011 (€ 12)
Order for social evening 8 April 2011	€ 20
Order for Brno Sightseeing 9 April 2011	Yes No (€ 25)
Order for post congress trip 1. 10 April 2011	Yes No (€ 60)
Order for post congress trip 2. 10 April 2011	Yes No (€ 60)
Payment method: Bank transfer Credit card