Aktuality

Groningen, April 3-4^th 2014

BEYOND FDG:

INTERNATIONAL SYMPOSIUM ON

PET TRACERS IN ONCOLOGY

Groningen April 3-4 , 2014

REGISTRATION FORM

Please complete this form and (e-)mail or fax it to Ms. S. Evers. Nuclear Medicine & Molecular Imaging,

University Medical Center Groningen, PO Box 30.001, 9700 RB Groningen, The Netherlands,

Telefax: +31-50-3611687, e-mail: symposiumngmb@umcg.nl

The symposium fee of € 250.00 (students with letter of institute € 150.00) should be paid before March 1, 2014,

using one of the following methods: Symposium fee after March 1, 2014, is € 300.00 (students € 200.00).

• bank transfer to account number 92 91 12 539 SNS Bank (IBAN NL80 SNSB 0929 1125 39,

BIC SNSBNL2A), Stichting Trace 2000, Bedum, The Netherlands

• credit card (see below).

Payment of the fee completes your registration. Registered attendees have access to all lectures, the

lunches and the Symposium Dinner.

Name:

Department:

Institution:

Address:

E-mail:

Telephone number:

I will also attend the pre-symposium workshop on April 2nd: State of the art production of

radiopharmaceuticals for PET imaging – Recent Developments.

Limited access on first come first service basis : n yes n no

Please indicate which is applicable:

n The symposium fee has been transferred to your bank account

n Charge credit card: n MasterCard n VISA

Card number |___|___|___|___| |___|___|___|___| |___|___|___|___| |___|___|___|___|

Expiration date ___ / ___

3 digit Credit Card Verification (CCV) # on the signature panel of your card |___|___|___|___|

Name of card holder (as shown on card)

Signature Date / /2014