REGISTRATION

Title:
Family Name:
First Name:
Profession:
Affiliation 1:
Affiliation 2:
 
Address for Correspondence:
 
Street:
Town:
Postal Code:
Country:
Telephone:
Fax:
E-mail:

METHOD OF PAYMENT

Bank transfer to:
"Dr. Einspieler-Dev.Neur"
Austrian PSK, A 1018 Vienna
Bank Code: 60.000
Bank Account: 72.344.701
BIC: OPSKATWW
IBAN: AT216000000072344701
 
Euro/Mastercard
Diners
VISA
Card Number:
Expiry Date (mm/yy)
Name on Card:
Signature:

If you prefer to pay by Credit Card, don´t submit the Registration form.
Print out the form and send it to:

Dr. Christa Einspieler
Institute of Physiology, Medical University Graz ,
Harrachgasse 21, A - 8010 Graz, Austria, Europe
Fax: +43 316 380 69 4266