Online registracija / Online Aplication

 

 
Ovaj obrazac je za registraciju jednog sudionika ili prateće osobe.
This form is to register one participant or accompanying person only.
 
MOLIMO KORISTITE SAMO VELIKA TISKANA SLOVA BEZ DIJAKRITIČKIH ZNAKOVA.
USE ONLY LATIN LETTERS WITH NO SPECIAL CHARACTERS.
 
   SUDIONIK / PARTICIPANT
Titula / Title:
* obavezno / required
Ime / First Name:
*
Prezime / Family Name:
*
Ustanova/Institucija/Bolnica:
Department/Institute/Hospital:
*
Adresa / Address:
*
Grad / City:
*
Poštanski broj / Zip-Post:
*
Država / Country:
*
Telefon-Mob / Phone-GSM:
*
Fax:
E-mail:
*
   KOTIZACIJE / REGISTRATION FEES
Liječnik / Physician
Specijalizant / Resident
Osoba u pratnji / Accompanying Person
Izlagač / Exhibitor
Ukupno / Total Amount: 
Kn
   HOTEL / TRANSFER RESERVATION
Rezervirati ću smještaj sam / I will arrange the Accommodation by myself
Rezervirati ću slijedeći smještaj sada / I will need the following reservation
   
REZERVACIJA HOTELA  
  HOTEL RESERVATION
Odaberite hotel / Choose the Hotel: 
Tip sobe / Type of Room: 
Dijeliti ću dvokrevetnu sobu s:
Sharing your Double Room with: 
* if double room selected
Datum dolaska / Arrival Date: 
02. 2010. / February, 2010
Datum odlaska / Departure Date: 
02. 2010. / February, 2010
Broj noćenja / Number of nights: 
Ukupno / Total Amount: 
Kn
   SVEČANA VEČERA / GALA DINNER (Free of charge)
Ne / No
Da / Yes
Ukupno / Total Amount: 
Kn
   DETALJI ZA RAČUN / INVOICE DETAILS
Snosim troškove registracije sam / I'am paying for the registration expenses by myself
Druga tvrtka snosi moje troškove / Other company is paying for my registration expenses
 
Označite troškove koje druga tvrtka snosi umjesto Vas:
Check the expenses that some company is covering for you:
 
  Kotizacija / Registration Fee
  Hotel
   
Institucija-Tvrtka / Institution-Company:
MB (croatian participants)/ VAT #:
Adresa / Address:
poštanski broj / Post-Zip:
Grad / City:
Država / Country:
   ZA PLATITI / PAYMENT SUMMARY
Kotizacija / Registration Fee: 
Kn
Hotel: 
Kn
Svečana večera / Gala Dinner: 
Kn
Ukupno / Overall Total: 
Kn
   
   METODA PLAĆANJA / METHOD OF PAYMENT
Kreditna kartica Online / Credit Card Online (Diners, American Express)
Kreditna kartica Offline / Credit Card Offline (Visa, MasterCard/Eurocard, Diners, American Express)
Bankovna uplata / Bank Transfer