Name of Society/Institution *

Address *

City *

Postal code *

Country *

Phone (incl. country code) *

Fax (incl. country code)

Website

E-mail *

Who are you? * Scientific/Medical Organization, Association or Society University/Teaching Hospital Hospital Governmental Organization Conference Organizer Other

If other (please specify):

Briefly describe your organisation and its structure

Briefly describe your organisation and its structure *

Does your Society/Institution organise international educational events? *

Does your Society/Institution organise international educational events? * Yes No

Name of Society/Institution to be invoiced *

Address *

City *

Postal code *

Country *

Phone (incl. country code) *

Fax (incl. country code) *

VAT number (if applicable)

Contact person (for questions regarding invoices)

Title * Mr Ms Dr Prof

First name *

Last name *

Job title

Address (at work) *

City *

Postal code *

Country *

Direct phone (incl. country code) *

Direct fax (incl. country code)

E-mail *

Do you regularly use commercial support for your educational programmes? *

Do you regularly use commercial support for your educational programmes? * Yes No

If yes, please indicate what kind of support it is (educational grant, advertising, etc.)

If yes, please indicate what kind of support it is (educational grant, advertising, etc.)

Have you previously organised events in this field?

Have you previously organised events in this field? Yes No

If yes, please provide us with details about the two most recent events in pneumology you have organised:

Details of Event 1

Title

City

Country

Start-date
(dd/mm/yyyy)

End-date
(dd/mm/yyyy)

Number of faculty members (speakers)

Number of participants

Countries the participants came from

Details of Event 2

Title

City

Country

Start-date
(dd/mm/yyyy)

End-date
(dd/mm/yyyy)

Number of faculty members (speakers)

Number of participants

Countries the participants came from

If you have not previously organised any Pneumology event, please give us a short description of your relevant experience in the field

If you have not previously organised any Pneumology event, please give us a short description of your relevant experience in the field

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Notification e-mail - Address