The Network for Advancement of Transfusion Alternatives (NATA)

19th Annual NATA Symposium – April 12-13, 2018 – Lisbon, Portugal SYMPOSIUM REGISTRATION FORM

 Ms.  Mr.  Dr.  Prof. (Please write in capital letters) Last Name: First Name: Function: Institution/Affiliation: Address: Post Code: City: Country: Phone: Fax: E-mail: V.A.T. number (if registered by a company):

Registration fee1, including taxes: Registration Type Until February 28, 2018 After February 28, 2018

 NATA Non-Member  € 440.00  € 520.00  NATA Member2  € 350.00  € 430.00  NATA Non-Member, Reduced Fee Country3  € 290.00  € 350.00  NATA Member2, Reduced Fee Country3  € 200.00  € 260.00  Physician in training, student, nurse,  transfusion practitioner, biomedical scientist4  € 150.00  € 150.00  One-day registration  € 280.00  € 300.00 Please specify:  April 12  April 13

1The fee includes the right to attend all plenary sessions and workshops. 2If you register as a NATA member, please specify your membership number: ______3Reduced fee countries are low and middle-income countries according to the World Bank classification (http://data.worldbank.org/income-level/LMY) 4On written confirmation of status. Cancellation policy: - cancellation before March 4, 2018, 90% refund of registration fee - cancellation after March 4, 2018, no refund

Total amount to be paid:

Payment  I am enclosing a cheque in Euros made out to MedEd Global Solutions  I am paying by credit card:  Visa  Mastercard Please provide: Cardholder name: ______Card number: _ _ _ _ _ / ______/ ______/ ______Security code (3-digit number at the back of your credit card) _ _ _ _ Expiry date: _ __ _/ ______(MM/YYYY)

Date: Signature:

Registration/Information NATA c/o MedEd Global Solutions, 27 rue Raffet, 75016 Paris, France Phone +33 (0)1 44 01 51 81 – Fax: +33 (0)1 44 01 51 80 – E-mail: [email protected]