22nd Budapest Nephrology School Nephrology, Hypertension, Dialysis, Transplantation Under the Auspices of ISN and ERA-EDTA 26 – 31 August, 2015 Application Form Please type or use block letters. Please complete and return it to [email protected], cc. [email protected], or fax: +36-1-374-7031 Personal Data Title:  Prof.  Dr.  Mr.  Mrs.  Miss Family name:______________________________________________________________________ First name:________________________________________________________________________ Affiliation:_________________________________________________________________________ Country:_________________________________ City:_____________________________________ Address: ______________________________________________ Postal code:_________________ Phone:* _________________________________ Fax:*____________________________________ *including the country and area code E-mail:____________________________________________________________________________ Private E-mail:_____________________________________________________________________ Please specify your dietary needs you may have: _______________________________________  YES I need Invitation Letter for visa purpose:  NO Registration fee Registration type Early registration until 22 May, 2015 Late registration from 23 May, 2015 Participant □ 650 Euro □ 700 Euro □ 750 Euro Accompanying Person □ 220 Euro □ 250 Euro □ 280 Euro On site Registration fee includes:  Attendance to nephrology refresher CME course  Certificate of Attendance  Refreshments, lunches and dinners  Social programs (Please mark if you would like to attend the respective program. We cannot guarantee for last minute applications on site.)        13th International Wine and Health Symposium (26 August, 2015) Evening Danube Cruise (27 August, 2015) Sightseeing Tour in Budapest with Parliament visit (28 August, 2015) Organ Concert at St. Stephen Basilica (29 August, 2015) □ □ □ □ □ Farewell Reception (30 August, 2015) 50% support for buying the book of Nephrology, Hypertension, Dialysis, Transplantation Eds: Thomas E. Andreoli, Eberhard Ritz, László Rosivall Hungarian hospitality Accompanying person's fee includes: (Please mark if you would like to attend the respective program. We cannot guarantee for last minute applications on site.) o 13th International Wine and Health Symposium (26 August, 2015) o Evening Danube Cruise (27 August, 2015) o Sightseeing Tour in Budapest with Parliament visit (28 August, 2015) o Organ Concert at St. Stephen Basilica (29 August, 2015) o Farewell Reception (30 August, 2015) □ □ □ □ □ □ APPLICANT’S NAME: ______________________ Accommodation Hotel Single Room Double Room Mercure Budapest Korona**** □ 69 Euro □ 64 Euro □ 84 Euro □ 72 Euro Hotel Erzsébet City Center*** Prices indicated in Euro per room, per night, including breakfast and applicable taxes. Modification in tax laws might cause changes in prices. Arrival date: ____________________________________________________________________ Departure date: _________________________________________________________________ Number of nights: _______________________________________________________________ Special requests: ________________________________________________________________ I share my room with: ____________________________________________________________ Hotel reservation will be made only on receipt of two-night hotel deposit. Payment Payment Total amount Participant Registration fee _____________ EURO Accompanying Person’s Registration fee _____________ EURO Two-night Hotel Deposit _____________ EURO GRAND TOTAL _____________ EURO Invoice  Please send me an invoice: Invoicing name and address: ___________________________________________________________ VAT number: _____________________________________ ________________________________ Reference number / person: ____________________________________________________________ Postal address: _____________________________________________________________________ APPLICANT’S NAME: ______________________ Method of Payment  Credit Card Please charge EURO ________ to my VISA  EC/MC  AMEX      Card number ________________________________________________________________ Cardholder’s name _________________________________________________________________ Billing address of the Cardholder _________________________________________________________________ Expiry date ________________________________ CVC Code only VISA and EC/MC (the last three digits on the back of the credit card where the signature is) Please note that our Bureau will debit your card in EURO.  Bank Transfer The registration fee(s) and the two-night hotel deposit have to be made to: Account holder’s name: Hungarian Kidney Foundation IBAN number: HU55 1176 3055 2470 9882 0000 0000 Bank’s name and address: OTP Bank, 1051 Budapest, Nádor utca 6. Swift code: OTPVHUHB Please indicate “SCHOOL 2015” and the name of the Participant(s). All charges due to bank transfers have to be paid by the sender. The name and address of the sender have to be marked clearly on every remittance.  On site (cash)  I have read and accept the cancellation terms as contained on the official website. Date _____________________________________ Signature __________________________________