Registration Form

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Title*:  ---Ms.Mrs.Mr. Degree:  ---Dr.Prof. Last name*:  First name*:  Middle initial(s):  Department:  Institution:  Address*:  Postal or ZIP code + city*:  Country*:  Phone:  Fax:  E-mail*:  Registration fee: before March 1, 2011      after March 1, 2011                     on-site   Members 325 EUR      375 EUR 400 EUR   Non-Members 375 EUR      425 EUR 450 EUR   Student 100 EUR      100 EUR 150 EUR   Africa/Eastern Europe 150 EUR      200 EUR 250 EUR   Accompanying persons 80 EUR      80 EUR 100 EUR Gala Dinner (55 EUR per person):   I will attend with    additional persons Pre Congress Hands On Workshop (free of charge)   I will attend the workshop  Liver Kidney Tx in PigsLiver Surgery in Pigs with Hydro-Jet, Cusa, bipolar Vessel Sealing DeviceRFA, LITT US CavitationOptical Imaging in Rodents Total amount: .00 EUR (calculated automatically by JavaScript) Payments to: Payee:  Universitätsklinikum Aachen Subject:  380295 Bank:  Sparkasse Aachen Bank code:  390 500 00 Account no.:  130 040 15 IBAN:  DE 27390500000013004015 BIC:  AACSDE33