ECPC 2023 Annual Congress and AGM

REGISTRATION FORM

Annual Congress 2023 - Friday 23 and Saturday 24 June

Annual General Meeting - Sunday, June 25, 2023

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* 1. Email address

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* 2. First name (as it appears on your passport)

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* 3. Last name (as it appears on your passport)

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* 4. Mobile phone number (Reachable before and during the event)
Please include country code, for example: +32 123 45 6789

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* 5. Is your organization a Member of ECPC?

Yes

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* 6. Are you Full or Associate Member?

Full Member

Associate Member

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* 7. Name of organization (in English)

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* 8. Country (Where organization is legally based)

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* 9. Registered Address (Where organization is legally based)

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* 10. Are you the legal representative of the organization?

Yes

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* 11. I confirm I will attend the ECPC AGM on Sunday, 25 June 2023, and will be voting on behalf of the organization

Yes, I confirm.

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* 12. I will be acting as Proxy Vote, on behalf of another organization:

Yes, I confirm I will vote on behalf of 1 Full Member.

No, I will not.

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* 13. Which organization will you be Proxy Vote for?

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* 14. Do you require a Visa to enter Belgium?

Yes

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* 15. Type of Travel Identification Document:

Passport

ID Card

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* 16. Identification document number

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* 17. Validity dates of Identification Document

Valid from:

Date

Date of expiry:

Date

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* 18. ECPC Non-Member Information: Company/Organization Name

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* 19. ECPC Non-Member Information: Company/Organization Address

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* 20. ECPC Non-Member Information: Company/Organization Phone Number

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* 21. ECPC Non-Member Information: Company/Organization Email Address

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* 22. Type of organization:

NGO

EU Institution

Governmental Body

Pharmaceutical /Biomedical Company

Medical Society

University / Research Institute

Press / Media

Consultancy Agency

Other (please specify)

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* 23. Role in Organization:

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* 24. What are your means of transportation to Brussels, Belgium?

Airplane

Train

Bus

Car - my own vehicle

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* 25. Traveling by car? Tell us the Number of kilometers to be covered and describe the itinerary

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* 26. Airport of departure or Station of departure (if you selected bus or train)

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* 27. Will you attend the dinner on the 23rd at the hotel from 8.00-10.00pm?

Yes

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* 28. Dietary Requirements

No specific dietary requirements

Vegetarian

Vegan

Lactose Free

Gluten Free

Nut Allergies

Seafood allergies

Other (please specify)

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* 29. Please, tick the box below

I, hereby, accept ECPC Privacy Policy

I, hereby, accept ECPC Travel Reimbursement Policy, including Cancelation and No-show Policy information herein. Please note that once you are approved for the travel grants, we will require a medical or force majeure certificate in case of cancellation of your trip, otherwise you and your organization will be asked to refund the cost of your participation (airfare and accommodation) incurred to ECPC. Thank you for understanding.

I, hereby, accept and understand that the ECPC 2023 Annual Congress and AGM will be photographed and
video recorded. ECPC may use the photos and videos of you (or your slides) on their
website and on social media, including publications, promotional materials, in articles and
potentially for publicity and marketing purposes. I can withdraw consent for this at any
time emailing to agmcongress@ecpc.org However, this will not apply to material already
published.

ECPC 2023 Annual Congress and AGM

REGISTRATION FORM

Question Title

* 1. Email address

Question Title

* 2. First name (as it appears on your passport)

Question Title

* 3. Last name (as it appears on your passport)

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* 4. Mobile phone number (Reachable before and during the event)Please include country code, for example: +32 123 45 6789

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* 5. Is your organization a Member of ECPC?

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* 6. Are you Full or Associate Member?

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* 7. Name of organization (in English)

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* 8. Country (Where organization is legally based)

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* 9. Registered Address (Where organization is legally based)

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* 10. Are you the legal representative of the organization?

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* 11. I confirm I will attend the ECPC AGM on Sunday, 25 June 2023, and will be voting on behalf of the organization

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* 12. I will be acting as Proxy Vote, on behalf of another organization:

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* 13. Which organization will you be Proxy Vote for?

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* 14. Do you require a Visa to enter Belgium?

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* 15. Type of Travel Identification Document:

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* 16. Identification document number

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* 17. Validity dates of Identification Document

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* 18. ECPC Non-Member Information: Company/Organization Name

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* 19. ECPC Non-Member Information: Company/Organization Address

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* 20. ECPC Non-Member Information: Company/Organization Phone Number

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* 21. ECPC Non-Member Information: Company/Organization Email Address

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* 22. Type of organization:

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* 23. Role in Organization:

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* 24. What are your means of transportation to Brussels, Belgium?

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* 25. Traveling by car? Tell us the Number of kilometers to be covered and describe the itinerary

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* 26. Airport of departure or Station of departure (if you selected bus or train)

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* 27. Will you attend the dinner on the 23rd at the hotel from 8.00-10.00pm?

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* 28. Dietary Requirements

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* 29. Please, tick the box below

* 4. Mobile phone number (Reachable before and during the event)
Please include country code, for example: +32 123 45 6789