2015 Speakers Patient Empowerment conference

1. Make your online registration available below;

2. After the deadline of registrations you will receive a confirmation including a link of EPF online travel agency if you need to book a flight;

3. If you travel by plane you will make your booking via EPF travel agency (see item 2) this way EPF will be directly charged for the cost of flight booking.

4. For other transport than flight you will need to use your own agency. You will be able to claim the reimbursement of your travel with the reimbursement form only after the event.

5. Please don’t book your travel before receiving the confirmation of your registration

Deadline for registation: 31 March 2015

For more information please contact Véronique Tarasovici at veronique.tarasovici@eu-patient.eu or +32 (0) 2 280 23 34.

2015 Speakers Patient Empowerment Conference PERSONAL DETAILS

Title (Mandatory)

Surname (Mandatory)

First Name (Mandatory)

Job Title (Mandatory)

Name of the Organisation (Mandatory)

Country (Mandatory)

Organisation postal address (Mandatory)

Office phone number (Mandatory)

Office FAX number

Mobile phone number

Email (Mandatory)

Please state any special requirements Mobility Vegetarian Use of wheelchair Sugar free Gluten Free Other

Other Special Requirements

TRAVEL Speakers are invited to make their own travel arrangements in line with EPF policy. A link to EPF online travel agency will be porvided with the confirmation of your registration. Transfers from/to airport will not be organised. Further information on travel options from the airport will be sent with final papers. ACCOMMODATION If needed a hotel room will be booked by the Secretariat in the same hotel as the venue. The booking will be done according to the date of arrival and departure mentioned in your registration form below.

Check-in Date

Check-out Date

One night accommodation is payable by EPF. Optional supplementary stay at the hotel venue would be at your own expense. If you wish staying additional nights, please provide below details of your credit card to enable us making reservation for you.

Name of cardholder

Card Type / Number

Card expiry date

ATTENDANCE

I will participate at the speakers' dinner on 19 May (Mandatory)

I will participate at the conference dinner on 20 May (Mandatory)

A thank you message should be seen following the submission of this form. If you don't see such a message this means that one of the mandatory field is not filled. Please check. Should you encounter any problems, please contact event organisers at veronique.tarasovici@eu-patient.eu

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2015 Speakers Patient Empowerment conference

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