EuroPACS'98 REGISTRATION FORM 

                          October 1-3, 1998, Barcelona, Spain

             Radiology Department, Hospital Materno-Infantil Vall d'Hebron  

                  Vall d'Hebron Hospitals, E-08035 Barcelona, Spain

        

        Family Name : ....................................................

        First Name  : ............................... Degree :............

        Address     : ....................................................

        ..................................................................

        ..................................................................

        City : ................................ PO code : ................

        Country : ........................................................

        E-mail : .........................................................

        Tel  : ......................... Fax : ...........................

                       [  ] Yes, I plan to submit an abstract

        

        Advanced Registration Fee (Before July 31, 1998):

         [ ] Non-EuroPACS Member:      40.000 ESP

         [ ] EuroPACS Member/Student:  20.000 ESP

         *** Late Registration Fee (later than July 31, 1998) *** :

                  [ ] Non Member:      50.000 ESP

                  [ ] EuroPACS Member: 25.000 ESP

                             Registration Subtotal: .................ESP



       Hotel Alimara (4*)     Hotel Barcelona (4*)   Hotel Wilson (3*)

         Venue area              City center           City center

      [ ]Single (12200 ESP)  [ ]Single (18000 ESP)  [ ]Single (13500 ESP)

      [ ]Double (15000 ESP)  [ ]Double (20000 ESP)  [ ]Double (17500 ESP)

        

      Hotel Condor (3*)       Hotel Numancia (3*)    Hotel Zenit (3*)

        City center             City center (west)     City center

      [ ]Single (12500 ESP)  [ ]Single (13500 ESP)  [ ]Single (11000 ESP)

      [ ]Double (13500 ESP)  [ ]Double (13500 ESP)

      [ ]Accompanying person; Name: .....................................  

      Arrival: ../../1998,  Departure: ../../1998,  total: .... Nights

                             Hotel Subtotal: .......................ESP

        

          (Registration + Hotel) Total Amount:......................ESP

                                (All amounts are in Spanish Peseta, ESP)

     Payment by: 

     [ ] Bank draft to: 

     Account holder: EuroPACS'98 - Fundacio Vall d'Hebron

     Bank: Banca Catalana (swift: cataesbb), account 015-4444-16-0011500298



     [ ] Charge my credit Card:  [ ] Visa    [ ] Master   [ ] Amex

     Card number:............................... Expiration:..../....  

     Signature:





     Date:..........

                     Fax this form to Organizing Committee: +34 93 2746775

                        or e-mail this form to : jpiquer@ar.vhebron.es

    For further information/particular arrangements contact Org. Committee