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7th Vienna Shock Forum - Online Registration

You can use the form below to register online with the 7th Vienna Shock Forum in association with the European Shock Society
November 13 - 16, 1999 - Hotel Hilton, Vienna

Before you start filling out the form be aware of the fact that you have to enter your credit card information to complete the registration and that sending credit card information over the internet is not 100% safe. You do this at your own risk.
First Name:
Surname:
Institution:
Area Code:
Town:
Street:
Country:
Telephone:
Fax:
E-Mail:
Fee (ATS/EUR) number of
participants 		ATS EUR
Member ESS 3700,- 268,89
Non-Member ESS 4000,- 290,69
Students, Nurses and
Technical Staff		 2500,- 181,68
Social Programm Persons
"Get Together" Cocktail
November 13th (free, but registration needed)
"Music and Leisure"
November 14th (free, but registration needed)
Major's reception
November 15th (registration needed, free)
I (We) agree to remit the above amount by Credit Card:
Cardtype: Visa          Mastercard
Card Number:
Card Expiration Date (MM/YYYY):
Cardholder's Name



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