Registration

First Name: *

Title:

Last Name: *

E-mail address: *

Department: *

Street address: *

Zip or Postal Code: *

Telephone: *

Country *

Institution: *

City: *

State or Province:

Fax:

Will participate in the Primer for young Investigators. *

Yes

Congress Dinner *

Will participate (Please add 15€ to your Registration fee.)

Will not participate.

Your registration is complete only after payment of registration fee.

Please submit payment to:

Account Holder: Universitätsklinikum Essen

Bank Name: Sparkasse Essen

IBAN: DE82360501050004900700

SWIFT-Code/BIC: SPESDE3EXXX

Payment Purpose/ Verwendungszweck 1: D/112-00002 (essential for proper allocation)

Payment Purpose/ Verwendungszweck 2: First, Last name

Upload here your proof of "Money-Transfer"

If you must pay later, please download the statement linked HERE and attach it instead of your proof of transfer

ERRS GBS 2017