Please return this registration form by 15 February 2018to the Conference secretariat:

AESGP7, Avenue de Tervuren | B-1040 Brussels | Belgium

Tel +32 2 735 51 30 | Fax +32 2 735 52 22 | E-mail : info@aesgp.eu

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Important note: This form is for the conference registration only. In case you wish a room at the SANA Lisboa Hotel, Avenida Fontes Pereira de Melo 8, 1069-310 Lisboa (Portugal), please click on this link. 

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

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

Title:..........................................................

Organisation:.............................................

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

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Phone:.......................................................

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

Arrival date:...............................................

Departure date:.........................................Please state below special dietary re-quirements, if any ..............................................................................

Please indicate if you intend to participate in the opening evening on Monday, 26 February 2018:

Yes, I will attend the opening evening

No, I will not attend the opening even-ing

REGISTRATION FEE: 500 Euro

I will transfer to the AESGP account:IBAN: CH 91 0027 9279 C876 28 31 5Swift: UBSWCHZH80A Union de Banque Suisse (UBS), 17 Chemin Louis Dunant, CH-1211 Geneva, Switzerland

Please tick this box in case you need aninvoice

Please note that AESGP is unable to ac-cept credit card payment at this point in time.

Please indicate which information should appear on the invoice:

Your Purchase Order Number: …………………......

Your Company VAT country identification & number (if applicable): …………………………………..

Invoice address (if different from the one stated before): ..........................................

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CancellationsFor cancellations received after 15 Febru-ary 2018, the whole fee is withheld. 

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

Signature: .................................................

26 - 27 February 2018

AESGP Conference with the Heads of EU Medicines Agencies

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