Polish Society
for Emergency Medicine

Last Name:
*
First Name:
*

doctor paramedic nurse
student sales representative

Job place:
*


Mailing address:
*
Phone/Fax:
*
e-mail:
*
Accompanying person:
yes no

Last and First Name of accompanying person:

Participation fee: PLN

Please pay close attention to all the information provided for billing purposes. Once order is issued, there will be no possibility to change it or to make any corrections on it.

Billing information:

First and Last Name, or company name:
*

City:
*
Postal Code:
*
Street:
*
Apartment number:
*
Tax Identification Number (NIP):
*

Booking:

	I am not making Hotel Reservation
	Gołębiewski Hotel: Single room accommodation (1 person)
	Gołębiewski Hotel: Double room accommodation (1 person) together with
	Gołębiewski Hotel: Double room accommodation (extra bed) together with
	Gołębiewski Hotel: Suite (max. 4 pers.) together with

Please provide me with the bill:
One Bill (food and accommodation)
Two Bills (food separately and accommodation separately)

The following part to be filled by sales representatives only


Sales equipment:

Tables (quantity):     Chairs (quantity):
Power access points: yes     no

Company Representatives: