ONLINE Registration If you are a human and are seeing this field, please leave it blank. Personal Information * Required Field First Name: * Last Name: * Company: * EASL number: ISPOR number: Mobile: * Fax: Email: * The confirmation will be sent via e-mail. Address (Billing Address) Country: * - Select One Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua And Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia And Herzegowina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo, The Democratic Republic Of The Cook Islands Costa Rica Cote D'Ivoire Croatia (Local Name: Hrvatska) Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Timor-Leste (East Timor) Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France France, Metropolitan French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard And Mc Donald Islands Holy See (Vatican City State) Honduras Hong Kong Hungary Iceland India Indonesia Iran (Islamic Republic Of) Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, Democratic People's Republic Of Korea, Republic Of Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macau Macedonia, Former Yugoslav Republic Of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States Of Moldova, Republic Of Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Kitts And Nevis Saint Lucia Saint Vincent And The Grenadines Samoa San Marino Sao Tome And Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia (Slovak Republic) Slovenia Solomon Islands Somalia South Africa South Georgia, South Sandwich Islands South Sudan Spain Sri Lanka St. Helena St. Pierre And Miquelon Sudan Suriname Svalbard And Jan Mayen Islands Swaziland Sweden Switzerland Syrian Arab Republic Taiwan Tajikistan Tanzania, United Republic Of Thailand Togo Tokelau Tonga Trinidad And Tobago Tunisia Turkey Turkmenistan Turks And Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela Viet Nam Virgin Islands (British) Virgin Islands (U.S.) Wallis And Futuna Islands Western Sahara Yemen Yugoslavia Zambia Zimbabwe Postal Code: * City: * Address: * Registration Please choose from below, regarding to your status: Early Bird (EB) OCTOBER 01, 2015 – APRIL 30, 2016 Late Registration (LR) MAY 01, 2016 –JUNE 23, 2016 EASL/ISPOR member* EB 300 €LR 400 € non EASL / ISPOR member EB 450 €LR 550 € Student / nurse ** EB: 130 €LR: 150 € MGT member EB: 200 €LR: 300 € * Only ACTIVE EASL / ISPOR members are entitled to the EASL / ISPOR members’ registration fee. ** Under 35 at the time of the congress and in training. Proof of age and proof of nurse status is mandatory. Accomodation * The rates includes the accomodation for the marked dates with breakfast, lunch, dinner and taxes. 1. Single standard room 219 EURO/person/night 23. June24. June 2. Double standard room 124.50 EURO/person/night 23. June24. June Requested roommate's data: First Name: Last Name: Company name: Mobile: E-mail: Cancellation/Refund Policy If your hotel reservation and registration is cancelled until March 1, 2016, the deposit will be refunded (50% of your booking). If your reservation is cancelled after March 1, 2015, or if you arrive later or leave earlier than on the dates indicated on your reservation form, the total accommodation amount will be charged. Payment Details Total in € Please invoice my organization I will be sending a bank transfer to Account Holder: MEDICONGRESS HUNGARY KFT. Bank: RAIFFEISEN BANK Swift Code: UBRTHUHB IBAN: HU22-12020407-01471761-00100004