Offline Registration form   (Bank transfer)	
 　　   4th World Congress of Clinical Safety
- Clinical Risk Management-
By International Association of Risk Management in Medicine (IARMM)
   	   　　　　　　　　　     　  　28th (Mon) - 30th (Wed) September, 2015
     Schloß Schönbrunn Apothekertrakt, Vienna, Austria

Registration deadline:  (for presenter) 25th July, 2015,  (for audience) 10th September, 2015
After you fill this registration form, fax it to the following registration office (+81-3-3817-6770).

Male □　　　　 　　Female □ 

------------------------------------------------------------------------   ------------------------------------------------------------------------               
▲ First name                                        ▲ Middle name    
      
------------------------------------------------------------------------   ------------------------------------------------------------------------
▲ Last name                                        ▲ Telephone number
                                                 
------------------------------------------------------------------------   ------------------------------------------------------------------------
▲ Title                                          　 ▲ Fax number
                                                 
------------------------------------------------------------------------   ------------------------------------------------------------------------
▲ Institution                                      　▲ Email address

▲	Postal address　   

A. Registration fee                                                     	
This registration is not valid before our confirmation of your payment.
Please mark ㇾ at your choice.  
(This delegate fee covers your lunch and coffee breaks)	IARMM non-member 
Price 	IARMM member and Student Price	
Delegate Fee for 3 days (The price is tax free.)	(     )  euro 550	(     )  euro 450	
Delegate Fee for 2 days (The price is tax free.)	(     )  euro 400	(     )  euro 300	
Delegate Fee for 1 day (The price is tax free.)	(     )  euro 200	(     )  euro 150	
Internet remote participant (3 days. The price is tax free.)	(     )  euro 400	(     )  euro 400	
Dinner Ticket
(not included in any package, *price includes VAT)	(     )  euro 130*	(     )  euro 130*	

* If your trust or organisation is not paying for your dinner ticket you should register as a delegate to receive your invoice for the delegate registration only and you can then register separately for your gala dinner tickets to receive a separate invoice.
 (Term condition)  On a case of cancellation, registration fee is not refunded.
When a delegate replaces with another person, email the request to the following office.

B. Hotel accommodation	
  Followings are our recommendation for your search.
  http://www.iarmm.org/4WCCS/hotelHD.pdf

Please note that IARMM in no way indorse these hotels or take responsibility for your booking with your chosen hotel. Your booking is a contract between yourself and your chosen hotel.

C. registration payment way	
　　  　　　　　　
In a case of credit card payment, please use our online payment system (PayPal Ltd) in the Congress homepage.
http://www.iarmm.org/4WCCS/
  .           

In a case of bank transfer, send the following bank account.
Bank name: Bank of Tokyo-Mitsubishi UFJ
Branch name: Hongo Branch
Branch number: 351
Account name: IARMM
Account number: 0111719
Sift code: BOTKJPJT

(Note)  For check use, you have to get an international check (Demand Draft) in your bank.  Thus, instead of check payment, you should use the following bank transfer. We don’t accept any check. 

-------------------------------------------------------
In a case of bank transfer payment, please fax this form to the following office till the registration deadline.
And, fax a copy of your receipt, too.

4th World Congress of Clinical Safety 2015 in Vienna
Administration Office
c/o World Health Risk Management Center
　　International Association of Risk Management in Medicine (IARMM)
(Tel / Fax) 　+81-3--3817-6770 
(Email)  manager@iarmm.org
4-7-12-102 Hongo, Bunkyoku, Tokyo,113-0033, JPN