Registration for medical courses

First Name: *
Last Name: *
Institution: *
Address: *
City: *
State/ Province:  *
Zip/Postal Code: *
Country: *
Phone: *
Fax:
E-Mail: *
Specialty: *	Resident Physician Student in Medical School Nurse Therapy operator Other
Participants: *	Participant with degree (fee required) Participant without degree

Payment

Failure to follow this procedure will result a participation in medical courses without receiving graduation diploma recognized by the Romanian College of Physicians.

Bank Account Holder: SC OPTOELECTRONICA-2001 SA
Bank: Banca Comerciala Romana
Branch: Unirea
Bank Account (RON): RO75RNCB0082044159490001
Bank Account (EURO): RO21RNCB0082044159490003

Please mention that the payment represents Medical Courses fee for Laser Bucharest 2010 Congress and please send us a copy of the payment to e-mail: info@laserbucharest.org

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