Preregistration for MEDNET99

PRE-REGISTRATION FORM

To pre-register for MEDNET99 please fill in the following. This is not a definite registration but only a "expression of interest to participate".

You will be automatically added to a mailing list keeping you updated about the congress. We will also assign you a participant ID, which will be emailed to you. Please use this ID whenever you correspond with the organizing comittee and when you submit you abstract.
Note: All fields marked with an * must be completed to process your pre-registration.

First name:	*
Last name:	*
Title:
Organization:
Street address:	*
Address (cont.):
City:	*
State/Province:	*
Zip/Postal code:	*
Country:	*
Work or Daytime Phone:
FAX:
E-mail:	*
Special area(s) of interest:
I am interested to participate as a	*	active participant (poster / oral presentation) passive participant (no own presentation) journalist sponsor / exhibitor
Do you want to get further information from the MEDNET99 mailing list?
E-mail alerting:	*	Yes No
Do you want your name and e-mail address made public to other participants?
Publish my name:	*	Yes No
Homepage URL:
Profession:
Define your new congress password:	*
Repeat the password:	*