Offline Registration form   (Bank transfer)	
 　　   6th World Congress of Clinical Safety
By International Association of Risk Management in Medicine  
                    (IARMM)
   	　　　 6th(Wed) – 8th (Fri) September, 2017
             Ambasciatori Palace Hotel, Roma, Italy
Registration deadline: 
(Presenter) From 1 April 2017 to 31 May 2017 
(Audience without a visa for Italy) From 1 April 2017 to 15 August 2017 
(Audience requested a visa for Italy) From 1 April 2017 to 15 July 2017
   After you fill this registration form, fax it to the following registration office (+81-3-3817-6770).
                
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▲ First name                                        ▲ Middle name    
      
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▲ Last name                                        ▲ Telephone number
                                                 
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▲ Title                                          　 ▲ Fax number
                                                 
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▲ 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.  
From April 2017 tol 15 August 2017)	Price	Price	
(This delegate fee covers your lunch and coffee breaks)	IARMM 
non-member	IRMPM member,
Student	
Delegate Fee for 3 days (The price is tax free.)	 (     ) €550	(     ) €450	
Delegate Fee for 2 days (The price is tax free.)	(     ) €400	(     ) €300	
Delegate Fee for 1 day (The price is tax free.)	(     ) €200	(     ) €150	

The registration is closed from 15 August 2017 to 5 Sep 2017..

Onsite registration  (6,7,8 Sep 2017)	Price	Price	
	IARMM 
non-member	IRMPM member, 
Student	
Delegate Fee for 3 days (The price is tax free.)	€650	€510	
Delegate Fee for 2 days (The price is tax free.)	€500	€360	
Delegate Fee for 1 day (The price is tax free.)	€250	€180	

The fee of a remote participant with internet live release is €400 for 3 days. There is no service of 1 day registration for remote participant.  Register before 15 September, 2017.

(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.

The delegate fees cover all printed materials (proceedings, journals, etc), catering for coffee breaks, lunch, and the other registration services.  It doesn’t include dinner.  The proceedings are provided by electronic versio.
The print version proceedings are not released.

A student and a resident should fax a copy of the ID card with photo.

B. Hotel accommodation	
  Followings are our recommendation for your search.
  http://www.iarmm.org/5WCCS/RECOMMENDED%20HOTELS%20listing%20for%20attendees.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/5WCCS/
  .           
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. 

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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.

6th World Congress of Clinical Safety 2017 in Rome
Administration Office
　International Association of Risk Management in Medicine (IARMM)
(Tel / Fax) 　+81-3--3817-6770 
(Email)    6wccs@iarmm.org
4-7-12-102 Hongo, Bunkyoku, Tokyo,113-0033, JPN