REGISTRATION

The registration fee includes:
• Participation in scientific works
• Congress kit
• Certificate of attendance
• CME certificate
• Abstract Book
• Coffee breaks and working breakfasts for the whole period
• 9th November Dinner and 10th November Dinner

Name / Surname(Required)

Name Surname

Email(Required)

Birth Place(Required)

Birth Date(Required)

Fiscal Code(Required)

Profession(Required)

Discipline(Required)

The undersigned declares to be:(Required)

Employee

Freelance

Agreement

Unoccupied

The undersigned:(Required)

Does not require CME credits

Requires CME credits

I have submitted an abstract.(Required)

Yes

Institute/Division/Organization(Required)

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Mobile phone

Fax

The undersigned declares that:(Required)

Have not been enrolled by a Commercial Sponsor

Have been signed up by the following Commercial Sponsor:

Have been signed up by the following Pharmaceutical company or manufacturer of medical devices:

Indicate Commercial Sponsor(Required)

Indicate Pharmaceutical Company or manufacturer of medical devices:(Required)

Please note that the maximum limit of training credits obtainable through direct recruitment is one-third of the training credits attributed to the reference three-year period. Furthermore, when compiling and submitting the report to the competent authorities containing the list of participants in the CME courses, the Provider must indicate the name of the sponsor in the appropriate spaces.

Signature(Required)

Date(Required)

In accordance with Legislative Decree 196/03, I authorize Nadirex International s.r.l. to process my personal data, both in paper and electronic format, solely for the purposes of the services related to the event, including the relationship with COGEAPS and AGENAS, in relation to ECM accreditation.

I also consent to receiving invitations for courses from Nadirex International s.r.l.(Required)

Yes

Signature(Required)

Date(Required)

BILLING INFORMATION

Name/Company Name(Required)

Institute/Division/Organization Address(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

VAT number

Fiscal Code(Required)

Unique code

PEC

Neuro HIV 2023(Required)

Price:

(€ 400,00 + 22% VAT)

Total

Payment method(Required)

Credit Card

Card Details

Cardholder Name

Bank transfer in favor of:
Nadirex International S.r.l.
Bank: Intesa Sanpaolo
Branch: Pavia Viale Cesare Battisti 18
BIC: BCITITMM
IBAN: IT66L0306911310100000069654
Please indicate "NeuroHIV - Novembre 2023" as the payment reference.