LODZ PLATELET CONFERENCE 11 Erfurt Conference on Platelets

LODZ PLATELET CONFERENCE 11 Erfurt Conference on Platelets

LODZ PLATELET CONFERENCE
jointly with
th
11 Erfurt Conference on Platelets
June 25th - 28th, 2006
Lodz, Poland
Please fill in the form and send by e-mail ([email protected]) or fax (+48 42 6312335)
Name
First name
Title
Dr
Prof
Sex
female
male
Institution
Street
Town
ZIP
Country
Phone
FAX
E-mail
Accompanying
person
Normal rate
150 Euro
600 PLN
Registration Fee
Reduced rate (students)
75 Euro
300 PLN
Accompanying person
50 Euro
200 PLN
Payment procedures
By bank cheque
payable to Technical University of Lodz
By bank transfer
Bank Name: PEKAO S.A. II o/Lodz
Account Name: Technical University of Lodz
Account Number: 25 1240 3028 1111 0000 2822 2228
SWIFT: PKOPPLPWLDZ
Please note: All payments should have notification “Platelet Conference” and the
participant’s or accompanying person’s name
Date of arrival: ___________________
_____________________________
Select payable at site
Date:
Lodz tour (15 euro)
Date of departure: _______________________
Arkadia–Nieborów –Walewice excursion (45 euro)
Signature:
Office address: 1 Stefanowskiego St. ; 90-924 Lodz; Poland; tel./fax. +48 (042) 631 23 35;;
e-mail: [email protected] ; www.p.lodz.pl/plateletconference