Faculty : logistics arrangements – March 21st to 22nd – Padua, Italy – CLIC ITALY 2019 Faculty : logistics arrangements – March 21st to 22nd – Padua, Italy – CLIC ITALY 2019 https://form.comnco.net/wp-content/uploads/2018/11/signature-mail-CLIC.jpg 520 100 Com&Guest Com&Guest https://form.comnco.net/wp-content/uploads/2018/11/signature-mail-CLIC.jpg 2 novembre 2018 2 novembre 2018 Faculty : logistics arrangements - March 21st to 22nd - Padua, Italy - CLIC ITALY 2019 Thanks for answering within fourteen days. Title*DrProf.MrMrsFamily name*First name*Date of birthMandatory to book your flights.E-mail*Mobile phone number*Please do not forget to write your country dialling code (+33 ; +49 ; +212 ; etc.)City*Country*Speciality*Affiliated Medical Center*AccommodationHOTEL* Night of March 20th (20th to 21st, day before the congress) Night of March 21st (21st to 22nd) Night of March 22nd (22nd to 23rd) I don't need accommodation Single room, breakfast and taxes included. The organizing committee covers a maximum of 3 nights. The extra and added night will be charged to you (and has to be paid upon arrival). If you need a double room, please keep us informed in the last part of this form "Special requests".Transport*Yes, I would like you to make my travel arrangementsNo, I will make my own travel arrangementsDeparture country*Departure city*Departure date*Departure time : Heure Minutes AM PM Return country (if it is not departure country)Return city (if it is not departure city)Return date*Return time : Heure Minutes AM PM Membership card type and number (airline, railroad company...)Download your passport or ID Card*Types de fichiers acceptés : jpeg, jpg, png, pdf, gif.Essential to book your travel. Thanks.Thank you for sending your receipts and your mailing address or your bank details after the congress to : Com & CoCLIC ITALY Registration15 Bd Grawitz - 13016 MarseilleOr by email to : firstname.lastname@example.orgSocial ProgramSocial Dinner - Thursday, March 21st*Yes, I take part to the Social DinnerYes, I take part to Social Dinner and I will be accompanied by one person (70,00 €)No, I do not take part to the Social DinnerMiscellaneousThank you for indicating below any food allergies we must know.Special RequestsPersonal data* By sending this form, I agree that my personal data might be used for the purposes of my logistic arrangements by the company or any service providers that may need it. PhoneCe champ n’est utilisé qu’à des fins de validation et devrait rester inchangé.