Registration

Name*
First name Family name
INAMI /RIZIV ID (for accreditation)
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Phone*
Fee type*
- SIZ members (70 €)
- ESICM/BESEDIM members (80 €)
- Non members (100 €)
- Non MD* (60 €)
* Certified in a statement signed by the Head of the Department
Statement
Accepted file types: jpg, pdf, doc, docx.
Date of payment*
- Prior to 01.06.2020
- From 01.06.2020
- On site
Date of payment*
- Prior to 01.06.2019
- From 01.06.2019
- On site
Date of payment*
- Prior to 01.06.2019
- From 01.06.2019
- On site
Date of payment*
- Prior to 01.06.2020
- From 01.06.2020
- On site
Total
0,00 €