[Last Name & First Name]
   

    Street & #
   

    Zip Code
   

    City/Town
   

    Country
   

    E-mail address
   

    Tel #
   

    Fax #
   

Registration Fee:

 ESHRE members

€ 60

Non ESHRE members

€ 80

Residents

free of charge

Transport:

 Needs bus transport to Maastricht:

€ 50

Does not need bus transport

€ 80

Total amount to be paid:

    €

Payment:

I send you an international cheque by mail, made payable to LIFE, Tiensevest 168, B-3000 Leuven

by Bank draft:
Bankaccount nr: 330-0658319-34
Iban: BE68 3300 6583 1934
Swift (BIC): BBRUBEBB
From LIFE, Tiensevest 168,
B-3000 Leuven, Belgium

Please remember that the full name of the person who registers has to figure on the bank draft.
The registration will be valid only once we have received a copy of the bank transfer
by e-mail to kris.meyhi@lifeleuven.be or
by fax: +32 16 27 01 97