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Monday, July 10, 2000
Registration Form
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Form (Word Document)
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Registration Form
Please complete and return form, together with your payment to:

Secretariat
7th World Congress on Heart Failure
PO Box 17659, Beverly Hills, CA 90209, USA
Tel: +1 310 657 8777
Fax: + 1 310 275 8922

Click here to download a Word file with this form.

Identification
Please complete this section accurately; the information you provide will allow us to correspond with you efficiently, and will also be used on your delegate badge at the Congress.

Field marked in red  are required.

Participant
Surname
First Name
Title
Mailing Address
No.
Street
Suite/Apt.
City
State/Province
Postal Code
Country
Telephone: (office hours)
Country code/city code/number
Fax:
Country code/city code/number
E-Mail:
Accompanying Persons
List only those individuals registering for the Accompanying Persons' Program:
Surname
First Name
Title
Surname
First Name
Title
Surname
First Name
Title
Registration Fees
Please mark the appropriate box(s) 
  Before
May 1, 2000		  After
 May 1, 2000
Participant  US$ 540.- US$ 620.-
Nurse, Technician, Trainee  US$ 320.- US$ 390.-
Student US$ 220.- US$ 270.-
Accompanying Person X US$ 160.- US$ 160.-
Farewell Dinner (Optional) US$70.- x

* letter of verification required
** valid student card required
Fees for PARTICIPANTS include: Participation in all scientific sessions, Congress kit, program, abstract book, printed material of the Congress and invitation to the Get-Together Reception.
Fees for ACCOMPANYING PERSONS include: Invitation to the Get-Together Reception and two half-day tours.

Payment
Please indicate amount enclosed and ensure that your fully completed registration form is sent together with your payment:
Total Fees: US$
Method of Payment
Option 1: Credit Card -will be charged US$ 
Visa  MasterCard  Eurocard  Diners  American Express
Number
Expiration Date (month/year)
Name as shown on card:
Surname
First Name:
For payment by Visa, please indicate home address if other  than mailing:
(No, Street ,Suite/Apt, City State/Province ,Country,  Postal Code)
Signature (printed form only) __________________________
Option 2 - Bank Transfer - with your name and address indicated on the reverse. If payment is made for more than one person or by a company, please make sure all names are indicated and return fully completed registration forms together with a copy of the bank transfer to the Secretariat. Please make drafts payable to: "7th World Congress on Heart Failure" and send to: Bank Leumi Le'Israel, Gan Ha'ir Branch, Tel-Aviv, Israel, Account Number PATAM 56142/73.
Bank charges are the responsibility of the payee and should be paid at source in addition to the registration fees.
Option 3 - Cheque made payable to: 7th World Congress on Heart Failure
Sent cheque number: 
Bank:

Cancellation Policy
Refund of Registration Fees will be made as follows:
Post-marked prior to May 1, 2000 - refund less 25%.
After this date, no refund can be made.