38th EORTC-PAMM Winter Meeting |

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First name*

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Last name*

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Title

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Specialty*

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Position held at current institute*

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Institution name*

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Institution department*

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Institution street address*

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Institution town / city*

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Institution country*

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Correspondence address

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Correspondence street address

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Correspondence town / city

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Telephone number*

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Mobile telephone number

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Email address*

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Emergency contact details*

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Secretary name

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Secretary telephone number

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Secretary email address

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We would be happy to arrange your accommodation at the meeting, if required

I would like the meeting organisers to arrange my accommodation
I will arrange my own accommodation
No accommodation required

If you prefer to arrange your own accommodation, please provide your hotel information in case we need to contact you

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Hotel arrival date (dd/mm/yyyy)

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Hotel departure date (dd/mm/yyyy)

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Participants are asked to arrange their own travel

I will organise my own travel and will request a refund
I will organise my own travel and will not request a refund

We would be happy to arrange your travel to/from the meeting, if required

I would like the meeting organisers to arrange my flights
I would like the meeting organisers to arrange my trains I will arrange my own travel No travel arrangements required

Dates

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Preferred return date (dd/mm/yyyy)

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Flight Details

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Preferred destination airport

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Frequent flyer numbers

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Name as it appears on your passport

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Date of birth (dd/mm/yyyy)

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Train Details

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Preferences

Seat preference (aisle/window)

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Additional travel requirements

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Confirmed arrival date (dd/mm/yyyy)

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Confirmed arrival time

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Confirmed arrival flight number

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Confirmed departure date (dd/mm/yyyy)

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Confirmed departure time (dd/mm/yyyy)

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Confirmed departure flight number

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Special dietary requirements (if applicable)

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Account holder name

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Bank name

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Bank address

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Account number

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Sort code (if applicable)

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IBAN (if applicable)

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BIC/SWIFT

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Routing instructions (if applicable)

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URSSAF number or RPPS number (if applicable)

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