Pleas fill in using BLOCK LETTERS

ET116 - EN
REGISTRATION FORM – EMBRYO TRANSFER COURSE
Theoretical basis and practical applications of techniques for collection of oocytes,
embryos and semen, cryopreservation and revitalization, embryo transfer and in vitro
fertilization (IVF) of oocytes
Please fill in using BLOCK LETTERS
Mr 
Mrs 
Title ______________________________
I am aware that this registration is binding.
First name(s): _____________________________________
(Please provide your full name)
WEB-Code
and Dates
Price in €
incl. 19% VAT
Surname: _________________________________________
ET116
01.02. - 05.02.2016
1600,00
Professional Education: _____________________________
Number of Participants
Max. 6 Persons
Date of Birth: ______________________________________
Native Language: __________________________________
Catering Information:
Meals:
□ Gluten-free
Vegetarian:
□ Lactose-free
□ Pork-free
□ Yes
Institution: ________________________________________
Specialization:____________________________________
__________________________________________________
I plan work with:
Street, Number: ____________________________________
☐ Oocytes
☐ Embryos and Sperm
__________________________________________________
☐ Cryopreservation of embryos, sperm and their
revitalization
☐ Embryos
Post Code: _______________ City: ____________________
Country: __________________________________________
Telephone: ________________________________________
☐ Embryo transfers and hysterectomies for the rehabilitation
or shipping
☐ In vitro fertilization - IVF
Cost Declaration Statement of the Cost Bearer:
Mobile Phone: _____________________________________
E-Mail: ___________________________________________
________________________________________________
Account / Transaction Number from the Institution
Invoice Address:
Institution: _____________________________________
_______________________________________________
Street, Number: _________________________________
________________________________________________
Signature / Stamp of Cost Bearer
Post Code: _____________ City:___________________
Country: _______________________________________
Address for sending the Course Certificate:
Institution/ Private: _______________________________
________________________________________________
VAT Identification Number for Foreign Institution only
(Please provide for invoicing purposes)
I herewith up on signing accept the General Terms and
Conditions (AGB).
_______________________________________________
Street, Number: _________________________________
Place, Date: ______________________________________
Post Code: ____________ City: ____________________
Country: _______________________________________
____________________________________________
Signature of the Participant
GWT – Gesellschaft für wissenschaftlichen Tierschutz mbH, tiz-bifo - AKADEMIE , Truderinger Straße 287, 81825 München
Tel.: +49-(0)89-420 24 833: Fax: +49-(0)89-420 24 850; Mobil: +49-(0)172-826 9482; E-Mail: [email protected]; Homepage: www.tiz-bifo.de
ET116 - EN
REGISTRATION FORM – EMBRYO TRANSFER COURSE
Theoretical basis and practical applications of techniques for collection of oocytes,
embryos and semen, cryopreservation and revitalization, embryo transfer and in vitro
fertilization (IVF) of oocytes
GWT – Gesellschaft für
wissenschaftlichen Tierschutz mbH
tiz-bifo - AKADEMIE
Truderinger Strasse 287
81825 München
Deutschland
GWT – Gesellschaft für wissenschaftlichen Tierschutz mbH, tiz-bifo - AKADEMIE , Truderinger Straße 287, 81825 München
Tel.: +49-(0)89-420 24 833: Fax: +49-(0)89-420 24 850; Mobil: +49-(0)172-826 9482; E-Mail: [email protected]; Homepage: www.tiz-bifo.de