Register for WANeurotech 2012

Registrations for the second World Association of Neurotechnology conference are now open.

*        and associated medical disciplines.
**      PhD Students and 1st Year Interns are required to provide a letter from their university
          stating that they have no additional income.
***    Students are those who have no other means of income and are not being paid for clinical
          or research work.  Student delegates are required to provide a copy of their student card
          or an offical letter from their head of department, university or institution, to be shown
          upon registration at the conference. 

• Note - Discounts are only available to delegates who are paying for their own registration.  If delegate fees are supported by their healthcare system or by a company, the full rates apply for their country.
• Conference Delegate Fees - Include entrance to the conference including all sessions, delegate materials and refreshments.  Fees do not include travel, accommodation or attendance at the Conference Dinner.
• Certificates of attendance will be issued to all conference delegates after the conference.
• If you are registering for a group of people please refer to our group registrations information before completing this form.

Registration Form

Personal Details

Fields marked with a * are required in order to submit the Registration

Title* :

First Name* :

Surname* :

Address 1* :

Address 2* :

Address 3* :

Zip/Post Code* :

Country* : -- Please Select a Country --/nAfghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo, the Democratic Republic of the Cook Islands Costa Rica Cote D'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Island and Mcdonald Islands Holy See (Vatican City State) Honduras Hong Kong Hungary Iceland India Indonesia Iran, Islamic Republic of Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, Democratic People's Republic of Korea, Republic of Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macao Macedonia, the Former Yugoslav Republic of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States of Moldova, Republic of Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory, Occupied Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syrian Arab Republic Taiwan, Province of China Tajikistan Tanzania, United Republic of Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela Viet Nam Virgin Islands, British Virgin Islands, U.s. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe

Email* : Invalid Format

Confirm Email* : Invalid Format

Password* :

Confirm P/W :

Telephone* :

Fax :

Hear about us?* : -- Select Referrer -- Conference Website Email Recommendation Journal Advertisement Leaflet at another event Invitation Other, please state

Other :

Booking Type

Type : Individual Group

Group Booking Details

Category* : -- Select Booking Category --Individual - £430.00 Eastern European - £315.00 Psychologists* - £190.00 PHD and 1st Yr Interns** - £210.00 Undergrad Medical Students*** - £70.00

Qty

Payable in £GBP :

Send Group List : Now Later

Please upload a list of the members of your group including Full Name and Email address in the following format: Microsoft Excel Spreadsheet
Group List* :

Individual Booking Details

Category* : -- Select Booking Category --/nIndividual - £430.00 Eastern European - £315.00 Psychologists* - £190.00 PHD and 1st Yr Interns** - £210.00 Undergrad Medical Students*** - £70.00

Payable in £GBP :

If you have a Delegate Code please enter your code EXACTLY, otherwise the system will ignore it.

Delegate Code :

Bursary Booking Details

Category* : -- Select Booking Category --/nBURWANT001 - £0.00 BURWANT002 - £215.00 BURWANT003 - £387.00

Amount Payable £GBP :

Method of Payment

Pay by : Credit Card Bank Transfer

This option must only be selected if you have a valid BURSARY Code
All Bursary Registrations will be manually checked to ensure they are valid

Credit / Debit card payments are made via our Secure Payment Provider.
* - Transactions will be listed as '2buysafe.com' on your credit card statement.
** - Credit Card transactions will be subject to a 4.5% surcharge.
*** - There is a limit of £1500 on Credit Card transactions. Any transactions exceeding £1500 should be completed using the Bank Transfer option.
Selecting this option will direct you to their secure payment form.

Card Type?* : -- Select Card Type -- Visa Mastercard American Express

Details of the Bank Account to Pay

Payment Details will be provided on your booking confirmation.

Human Verification

In order to prevent fraudulent submissions by 'bots' we use a human captcha system, please enter the exact characters (without spaces) you see in the graphic below in the box provided

Verify* : Reload Image

 

Acceptance of Privacy Policy and Terms

Agree to Terms : Yes No

Please tick the above to indicate that you agree to our Privacy Policy and Terms of Business. We will not be able to process your registration unless you agree.

Page Last Updated : 18-02-2012