BSRM Registration

Registration form - 47th BSRM Scientific Meeting

25 March 2022, DoubleTree by Hilton Brussels, Rue Gineste 3, 1210 Brussels

First Name *

Last Name *

Title *

Institute

Street & number *

Zip Code *

City *

Country

Vat Number

Email *

RIZIV number

Format 1-12345-12-340

Date of birth

Day Month Year

Language

Profession *

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Invoice Company

Invoice Title

Invoice First Name

Invoice Last Name

Invoice Department

Invoice Street & Number

Invoice Zip Code & City

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Invoice VAT Number

Invoice Remarks

Registration fee includes BSRM Membership fee 2022
I want to participate to the scientific meeting (25 March 2022)

Registration as: *

75 Euro - Clinician, reproductive biologist or other 40 Euro - Paramedical (midwife, nurse, lab technician) or resident in training, students (Master, PhD, post-doc..) Free - Membership 2022 already paid-up

Calculation

Payment method:

Bank transfer Visa / mastercard

Total

EUR Description

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Payment policy
Full payment has to be made to the BSRM account with reference: “Name + 47th Meeting”. IBAN number: BE79 3101 2631 7833, BIC: BBRUBEBB, Bank: ING.

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By registering for the BSRM Scientific Meeting, you agree to receive emails from BSRM & the sponsors.