Seattle Genetics MTI 2019 |

Seattle Genetics MTI 2019

Many thanks for agreeing to participate as a speaker at Seattle Genetics’ Meet the Investigator session which is being held on Monday 30 September 2019 during the ESMO annual congress in Barcelona, Spain.

To allow Seattle Genetics to generate a contract to cover your participation in this event, we would be grateful if you could complete all fields indicated below. By completing this online form, you agree that KMC and Seattle Genetics can use your information for the purposes of generating this contract. The information provided will not be used for any other purpose, stored or distributed to any other parties.

Personal information Dietary requirements Honorarium payment

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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 postcode / zipcode

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Institution country*

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Correspondence address

Same as institution address

Correspondence street address

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Correspondence town / city

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Correspondence postcode / zipcode

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Correspondence country

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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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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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Please ensure you have entered the correct information into each required field

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