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ECPC 2023 Annual Congress and AGM
REGISTRATION FORM
Annual Congress 2023 - Friday 23 and Saturday 24 June
Annual General Meeting - Sunday, June 25, 2023
OK
*
1.
Email address
(Required.)
*
2.
First name (as it appears on your passport)
(Required.)
*
3.
Last name (as it appears on your passport)
(Required.)
*
4.
Mobile phone number (Reachable before and during the event)
Please include country code, for example: +32 123 45 6789
(Required.)
*
5.
Is your organization a Member of ECPC?
(Required.)
Yes
No
*
6.
Are you Full or Associate Member?
(Required.)
Full Member
Associate Member
*
7.
Name of organization (in English)
(Required.)
*
8.
Country (Where organization is legally based)
(Required.)
*
9.
Registered Address (Where organization is legally based)
(Required.)
*
10.
Are you the legal representative of the organization?
(Required.)
Yes
No
*
11.
I confirm I will attend the ECPC AGM on Sunday, 25 June 2023, and will be voting on behalf of the organization
(Required.)
Yes, I confirm.
No
*
12.
I will be acting as Proxy Vote, on behalf of another organization:
(Required.)
Yes, I confirm I will vote on behalf of 1 Full Member.
No, I will not.
*
13.
Which organization will you be Proxy Vote for?
(Required.)
*
14.
Do you require a Visa to enter Belgium?
(Required.)
Yes
No
*
15.
Type of Travel Identification Document:
(Required.)
Passport
ID Card
*
16.
Identification document number
(Required.)
*
17.
Validity dates of Identification Document
(Required.)
Valid from:
Date
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February
March
April
May
June
July
August
September
October
November
December
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1901
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Date of expiry:
Date
January
February
March
April
May
June
July
August
September
October
November
December
1900
1901
1902
1903
1904
1905
1906
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1910
1911
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Sunday
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Sa
Saturday
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18.
ECPC Non-Member Information: Company/Organization Name
(Required.)
*
19.
ECPC Non-Member Information: Company/Organization Address
(Required.)
*
20.
ECPC Non-Member Information: Company/Organization Phone Number
(Required.)
*
21.
ECPC Non-Member Information: Company/Organization Email Address
(Required.)
22.
Type of organization:
NGO
EU Institution
Governmental Body
Pharmaceutical /Biomedical Company
Medical Society
University / Research Institute
Press / Media
Consultancy Agency
Other (please specify)
23.
Role in Organization:
*
24.
What are your means of transportation to Brussels, Belgium?
(Required.)
Airplane
Train
Bus
Car - my own vehicle
25.
Traveling by car? Tell us the Number of kilometers to be covered and describe the itinerary
26.
Airport of departure or Station of departure (if you selected bus or train)
27.
Will you attend the dinner on the 23rd at the hotel from 8.00-10.00pm?
Yes
No
*
28.
Dietary Requirements
(Required.)
No specific dietary requirements
Vegetarian
Vegan
Lactose Free
Gluten Free
Nut Allergies
Seafood allergies
Other (please specify)
*
29.
Please, tick the box below
(Required.)
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.
Current Progress,
0 of 29 answered
