Congress on GYNECOLOGY & INFERTILITY

ob/gyn congress

Please complete this form online or PRINT in BLOCK LETTERS and FAX / AIRMAIL to:
Secretariat:
2nd Cogi Congress
P.O. Box 50006, Tel Aviv 61500, Israel
Tel: +972-3- 5140000,
Fax: +972-3- 5140044 / 5140077,
E-mail: controversies@kenes.com

Participants Identification
Please complete this section accurately. The information you provide will allow us to correspond with you efficiently.

(fields marked in red are obligatory)

Family Name:

First Name:

Initials:

Title:

Institution:

Dept.:

Mailing Address:

Address:

City:

Zip:

State/Province:

Country:

E-mail:

Telephone:


Country Code	City Code	Number	Extension

Fax:


Country Code	City Code	Number

Accompanying Persons
Please list only those individuals registering for the Accompanying Persons' Program:

Family Name:	First Name:	Title:
Family Name:	First Name:	Title:
Family Name:	First Name:	Title:

Registration Fees
Please check the appropriate box/s:

	After July 15, 2001
Participants	Euro 580
Accompanying Persons:	Euro 200
Number of accompanying persons:
Total Registration Fees: EURO

Accommodation

Type of room required:

Single Double Other

First Choice Hotel:

Second Choice Hotel:

Check In Date dd/mm:

Check out Date dd/mm:

Total nights:

* I will share my
accommodation with:

Family Name:

First Name:

Hotel Deposit: EURO 250 (A deposit of Euro 250 is requested per room)

Tours

Tour To:	Date:	Hours:	Rate:	No. of Seat/s:
1. Louvre	Friday, September 7	14:30 - 17:30	Euro 40
2. Versailles	Sunday, September 9	09:00 - 13:00	Euro 56
3. Giverny	Sunday, September 9	09:00 - 17:30	Euro 140
Total Tours Fees:	EURO

Payment
Please indicate the amount enclosed and preferred mode of payment. Please ensure that you send your fully completed registration and accommodation form together with your payment:

Option 1:
Credit Card - Payments will be charged in US$ according to the rate of exchange to the Euro on date of payment

Credit card type:	Visa MasterCard Diners
Number:
Expiry Date (month/year):
Name as shown on card:
Family Name:
First name:
Signature printed form only	__________________________
Date (day/month/year) printed form only	__________________________
Passport number:

Option 2:
Bank Transfer - with your name and address indicated on the reverse. If payment is made for more than one person or by a company please make sure all names are indicated and send fully completed registration and accommodation forms together with a copy of the bank transfer. Please make drafts payable to "COGI 2" and send them to
Bank Leumi Le'Israel, Gan Hair Branch, Tel-Aviv, Israel, Account number 654-/56185/55
Bank charges are the responsibility of the payee and should be paid at source in addition to the registration and accommodation fees.

Option 3: (with printed form only)
Cheque made payable to: "COGI 2"

Enclosed cheque number: __________________
Bank: _________________________________

Option 4:
Western Union Quick Pay
Pay in cash in local currency with Western Union Quick Pay. Take your payment to the nearest Western Union location and complete the blue Quick Pay form. The form must be completed with the following information:
Company name: Kenes Tours Local/Code City: KENES, IK,
Account No.: COGI2 Name/Department: Accommodation and Registration
Date, Signature.

By signing this form you authorize Kenes to charge the above credit card for the balance of your account two weeks prior to your arrival for services ordered.

	[Home Page] [Committees][Welcome Note] [Sponsors][Congress Program][Preliminary Timetable][General Information] [Abstract Submission][Travel & Accommodation] [Request for Information][Registration Accommodation &Tours Form] [Previous Congress 1999][1999 Book of Proceedings]