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Modalità di Partecipazione *

RES
FAD

Specify RES Type *

CONGRESS NON-MEMBERS OF MICROBIOTAMI ASSOCIATION
CONGRESS MEMBER SOF MICROBIOTAMI ASSOCIATION
CONGRESS YOUNG

FAD *

FAD CONGRESS
CONGRESS YOUNG

Specify CONGRESS YOUNG *

Post-graduate student
Scholarship fellow
Student
Research fellow

The registration fee includes:

partecipation in scientific works
congress kit
certificate of partecipation and ECM Certificate
Coffee breaks and working launches as programme
welcome cocktail of Monday 5^thdecember 2022
post event educational material
abstract book

Congress Young must be UNDER 35

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Name *

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Fiscal Code (for italian resident)

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Employee/Freelance *

Employee
Freelance
Partecipant
Employment free

ECM

I request CME credits
Does not require CME credits

I presented an abstract

SI
NO

MicrobiotaMI partner *

SI
NO

Partecipo al Welcome cocktail di lunedì 3 Aprile *

SI
NO

Eventuali intolleranze alimentari

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POSTAL CODE *

Institute/Division/Body *

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POSTAL CODE

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The undersigned declares that he/she:

has NOT been registered by a Commercial Sponsor
HAS been registered by the following Commercial Sponsor

Azienda Farmaceutica o produttrice di dispositivi medicali (Pharmaceutical Company or medical device manufacturer)

Please remember that the maximum number of educational credits obtainable by means of direct recruiting is one third (1/3) of the educational credits attributable to the 3-year reference period, and that the Provider must specify the sponsor’s name in the indicated spaces when the report con-taining the list of participants in CME courses is compiled and sent to the competent bodies.

Signature

Data

Pursuant to Italian Legislative Decree 196/03, I authorise Nadirex International s.r.l. to process my personal data both in hard copy and in electronic form exclusively for purposes of the services related to the event, including relations with COGEAPS and AGENAS, in relation to CME certification. I also agree to receive the invitation to courses organised by Nadirex International s.r.

I also agree to receive the invitation to courses organised by Nadirex International s.r.l

SI
NO

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BILLING DATA

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PEC

RES - Not MicrobiotaMi members

Prezzo: 305,00 €

€ 250,00+55,00 VAT 22%

RES - MicrobiotaMi members

Prezzo: 244,00 €

€ 200,00+44,00 VAT 22%

RES and FAD Congress Young Members of Microbiotami Association Under 35

Prezzo: 200,00 €

€ 163,94+36,06 VAT 22%

FAD Congress

Prezzo: 250,00 €

€ 205,00+45,00 VAT 22%

Total

0,00 €

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Il campo Carta di credito è disabilitato, i pagamenti Stripe non sono abilitati nelle impostazioni del modulo.

Bonifico Bancario a favore di:
Nadirex International S.r.l. sul c/c di Intesa Sanpaolo Filiale di Pavia Viale Cesare Battisti 18 BIC: BCITITMM IBAN: IT66L0306911310100000069654
Si prega di indicare come causale di versamento “Congresso nazionale Microbiotami 2022”

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