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3rd EYE DOCTOR WORLD CUP CHAMPIONSHIP
 
Registration Form

Please fill in and send this form
IF THE REGISTRATION IS CORRECTLY COMPLETED, YOU WILL RECEIVE CONFIRMATION BY E-MAIL

*Required fields
Personal data
TITLE
NAME*
FAMILY NAME*
DATE OF BIRTH*
GENDER*: MALE     FEMALE
ADDRESS*
POSTAL CODE*
CITY*
STATE*
PHONE
FAX
EMAIL*
ACCOMPANYING PERSON'S NAME
IF PARTICIPATING TO THE RACES

BIRTH-DATE:

GENDER:MALE     FEMALE
C.F./VAT*
Institute/Organization Data
INSTITUTE/ORGANIZATION
POSITION WITHIN INSTITUTE/ORGANIZATION
ADDRESS
POSTAL CODE
CITY
STATE
PHONE
FAX
EMAIL
Invoice details for registration fee*
COMPANY DESIGNATION/NAME*
P.IVA/VAT*
ADDRESS*
POSTAL CODE*
CITY*
STATE*
Registration fee (VAT included)
All Races 50,00 €
No. of participants to All Races:

  
Friday, January 23rd

Only for Super G

20,00 €
No. of participants to Super G:

  
Only for Slalom 20,00 €
No. of participants to Slalom:

  
Only for Slalom parallel 20,00 €
No. of participants to Slalom parallel:

  
Saturday, January 24th

Only for Giant slalom

20,00 €
No. of participants to Giant slalom:

  
Please specify if: Ophthalmologist
Doctor
Optician
Ophthalmic company
family/friends


Payment methods
Bank transfer made out to:
Congressi Medici Oculisti Srl
BANCA INTESA SAN PAOLO
IBAN
IT26 A030 6903 2131 0000 0005 437
(send copy of transfer by fax to: +39 06 4468403)
On-Line Credit Card
(Once you click on the submit button you will be redirected to the page for payment on a protected website)		         
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