PACKAGE EUROPE – Logistics arrangements – CLIC 2019 PACKAGE EUROPE – Logistics arrangements – CLIC 2019 https://form.comnco.net/wp-content/uploads/2018/10/Capture-d’écran-2018-10-03-à-11.01.32.png 252 79 Com&Guest Com&Guest https://form.comnco.net/wp-content/uploads/2018/10/Capture-d’écran-2018-10-03-à-11.01.32.png 3 octobre 2018 3 octobre 2018 PACKAGE EUROPE - Logistics arrangements - CLIC 2019 Thanks for answering within 15 days * field mandatory Family name*First name*E-mail adress*Cell phone number*Country*City*Affiliated Medical Center*N° RPPS (Répertoire Partagé des Professionnels de Santé)This number is only for french physician.RegistrationI register as :*PhysicianFellowOtherOther (please indicate your speciality) :Could you please precise your speciality :*Vascular surgeonInterventional radioligistInterventional cardiologistAngiologistOtherOther (please indicate your speciality) :*How many peripheral endosvacular intevention do you practice per year ?*How many peripheral endosvacular heart interventions are performed in your center per year ?*What do you perform in your daily practice ?* Coronary angioplasty Peripheral angioplasty Structural heart interventions Rhythmology Interventional radiology Endovascular procedures Interventional radiology Vascular surgery Cardiac surgery How have you heard about the CLIC Congress ?*NewsletterWebsite (browser)BrochureIndustryPeerOtherPlease indicate the name of your colleague?*Please indicate which industry*Other (please specify)*What are the reasons why you want to attend this Course ?*AccommodationDo you need acommodation ?*YesNoSelect the night(s) according to your package* Night of March 20th, 2019 Night of March 21th, 2019 Single room, breakfast included. The extra and added night will be charged to you (and has to be paid directly to the Hotel). If you need a double room (charged to you), please keep us informed in the part below. If you will be accompanied by one person (€).Special accommodation requestsIf you don't want us to take care of your hotel, please note that we will not refund the hotel you book on your side. TransportAirport and/or station tranfers will be handled by the organization. You will receive detailed information in your travel book few days before your departure by email. Your flight will be in economic class, if you wish to travel in business class, it will be to your own charge.Do you need a transportation booking?*YesNoDeparture city*Departure date*Select your time slot for your departure*On morningOn afternoomOn eveningReturn city (if it is not departure city)Return date*Select your time slot for your return*On morningOn afternoomOn eveningMembership card type and number (airline, railroad company...)Preferred Airline companyDonwload your passport or ID Card*Essential to book your travel. Thanks.Special travel requests (aisle, window...)If you decide to make your own travel arrangements, thank you for sending your receipts and your mailing address or your bank details after the congress to : Com & Co 15 Bd Grawitz 13016 MarseilleOr by email to : email@example.comWe will proceed to your refund by check or by bank transfer within 4 weeks, on a 700€ basis for Italy. If you use your personal vehicle, the allowances of refund will be calculated on a " Mappy " basis.SOCIAL PROGRAMSOCIAL DINNER (March 21st) Yes, I take part to the gala dinner I will be accompanied by one person (70€) No, I do not take part to the gala dinner 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. EmailCe champ n’est utilisé qu’à des fins de validation et devrait rester inchangé.