PARTICIPANT REGISTRATION FORMEFGCP Multi-Stakeholder Workshop onCommunicating Clinical Trial Results to Meet Public Needs - A Meaningful Future for Lay Summaries -29 May 2015, Thon Hotel EU, Brussels, Belgium

Please use CAPITAL LETTERS or TYPE and return this form to: conferences@efgcp.eu • Fax: +32 2 503 31 08

EFGCP Secretariat – Rue de l’Industrie 4, BE-1000 Brussels, Belgium - Tel.: +32 2 732 87 83 • www.efgcp.eu

Registration Details Mr. Ms. Dr. Prof.

Family Name:.......................................................................... First Name:............................................................................Position:.................................................................................. Department:...........................................................................Organisation/Company:..........................................................................................................................................................Address:..................................................................................................................................................................................Zip code:..............................Town:......................................... Country:.................................................................................Phone:.................................................................................... Fax:........................................................................................Email:......................................................................................................................................................................................

Specific diet requirements (vegetarian, allergies …): …………………………....................................................................

If you need any other specific facilities (wheelchair access …), do not hesitate to inform the EFGCP Team .

Registration Fee

Become an EFGCP member when registering to this workshop and benefit from the discounted members’ rate from now on (further details are available on the membership webpage).

Members of EFGCP-EFPIA

+ VAT 21% Non-Members + VAT 21%

Registration Fee € 650.00* + € 136.50 € 750.00 + € 157.50

Reduced Registration Fee (academia, reg. authorities, ethics committees, associations)

€ 150.00* + € 31.50 € 250.00 + € 52.50

Students and Retired Delegates € 100.00* + € 21.00 € 100.00 + € 21.00

The registration fee includes workshop material, coffee breaks and lunch.

*I confirm my following membership is valid:

EFGCP–Individual EFGCP–Institutional EFGCP–Corporate EFPIARepresentatives of EFGCP Institutional and Corporate Members may directly benefit from the EFGCP Members’ rate (check if your organisation is a member on www.efgcp.eu).

PATIENT ORGANISATIONS: benefit from a waiver or one of the 10 grants available to fund your participation in the workshop. Contact the EFGCP Team .

Cancellation Policy

All cancellations must be in writing. Cancellations received before 7 May 2015 are subject to a charge of 25% of the registration fees for administrative costs. From 7 May 2015 on, full payment will be requested and refunds will not be provided. Replacements by colleagues, i.e. transfer of the registration at no extra cost, are much welcome.

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Way of Payment

BANK TRANSFER All charges to be borne by principal, to the order of the EFGCP.Account Holder: EFGCP Events Bank Name: ING, Brussels, Belgium BIC/Swift BBRUBEBB

Account #: 310-1960818-49 IBAN: BE97 3101 9608 1849 CommunicationInvoice # Delegate’s name

For payments by Bank Transfer: to comply with new EU invoicing rules as of 01/01/21013, a pro forma invoice will be sent along with the confirmation of registration. Once payment is received (prior to the event!), the official invoice will be issued.

CREDIT CARD: American Express Mastercard VISACardholder: .......................................................... Amount: …………….…….…….+……….………VAT Card #: .................................... Expiry date: .................... Security Code (CVC): ...................................

Date: .................................... Signature: ..................................................................................................

For payments by Credit Card: The official invoice will be sent upon receipt of payment from the Credit Card operator.

Billing and VAT InformationOrganisation/Company: ....................................................................................................................................................VAT #: ...............................................................................................................................................................................IF DIFFERENT FROM ABOVE:Contact Person: ................................................................................................................................................................Position: ........................................................................................ Department: ..............................................................Address: ............................................................................................................................................................................Zip code: ............................. City: ................................................ Country: ....................................................................Phone: .......................................................................................... Fax: ...........................................................................Email: ........................................................................................... Purchase Order # or other reference: .......................

IMPORTANT: Hotel and travel reservations should be made ONLY after receipt of written registration confirmation from EFGCP. If you have not received your confirmation within five working days, please contact the EFGCP Secretariat.

Data Protection Statement & Personality / Image RightsBy filling out the registration form, the participant gives consent that EFGCP can process the data provided within the framework of the conference and allow photographs to be made during the conference. This includes, unless registered participants object, all handling needed for the applicant’s participation at the event and for the drafting of a list of participants which will be distributed at the conference, and placing photographs in the pictures gallery accessible only by participants and EFGCP members, in the EFGCP newsletter or selecting some for articles on the conference in a journal or newspaper, or in any other web/printed publication.

Right of access: applicants have a right to access and ask for changing or deleting their personal data, which will be kept by EFGCP.

EFGCP would like to contact you occasionally to keep you informed of future EFGCP events and other relevant information. If you do not wish us to do this, please tick this box to be removed from our general distribution list

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