International Society of Pharmacovigilance

Uppsala Monitoring Centre

Pharmacovigilance concepts and tools in Latin America

4th ISoP-UMC training course, 04-06 September 2017, InterContinental Miramar Hotel, Panama

APPLICATION FORM

(Please complete the form – one form per person)

The cost for 3-day seminar (04, 05 and 06 September 2017):

o 450 Euros (High Income countries*, members of ISoP)

o 560 Euros (High Income countries*, non members of ISoP)

o 350 Euros (members of ISoP)

o 400 Euros (non members of ISoP)

o 300 Euros (Ac/Gvt LATAM) Academics and regulatory/gvt bodies should contact ISoP Administration for registration as places are limited.

*Applicants working in the following countries:Andorra, Australia, Austria, Bahrain, Belgium, Brunei Darussalam, Canada, Chile, China, Croatia, Cyprus, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hong Kong SAR China, Iceland, Ireland, Israel, Italy, Japan, Korea, Rep., Kuwait, Latvia, Liechtenstein, Lithuania, Luxembourg, Macao SAR China, Malta, Monaco, Netherlands, New Zealand, Norway, Oman, Poland, Portugal, Puerto Rico, Qatar, Russian Federation, Saudi Arabia, Singapore, Slovak Republic, Slovenia, Spain, Sweden, Switzerland, Taiwan ROC, United Arab Emirates, United Kingdom, United States.

The cost includes lunch, coffee breaks but does not include bank charges, accommodation, dinner or travel.

Information on hotels in Panama city available from the ISoP Administration office or website (isoponline.org)

Payments (payments must be net of bank charges):

q  Bank transfers to: NatWest bank, Uxbridge branch – 48 High Street, Uxbridge, Middlesex UB8 1UT – UK - Account No: 68010788 - IBAN: GB93 NWBK 6072 0668 0107 88 - IBAN BIC/SWIFT: NWBK GB 2L Payable to: International Society of Pharmacovigilance (ISoP). Please quote your surname/TC - on the transfer and send a copy of the bank transfer form with the application form to ISoP. Payments must be net of bank charges.

q  Credit-Debit Card | Payment Online. To start using online registration payment go to www.isoponline.org (under ‘ISoP UMC Training’) and follow the on-screen instructions. AMEX, VISA, and MasterCard accepted. Please note, when paying with a credit card, 12 euros will be added to cover bank charges to ISoP

Title: Mr | Ms | Dr | Prof / ISoP Member? YES | NO
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Any dietary or other special requirements?
Which hotel are you staying in?
Date: / Signature:

Please complete and send this form and payment before 10t August 2017 to:

International Society of Pharmacovigilance-ISOP Secretariat Ltd, 140 Emmanuel Road, London SW12 0HS, UK

Telephone and fax: +44 (0)20 3256 0027 – E-mail: – www.isoponline.org

Cancellations must be received in writing. Cancellation notice should be advised at least prior to 01 July 2017 otherwise no refund will be applied. By completing this registration form you are agreeing to ISoP’s cancellation policy.

Members of ISoP are eligible for “member” rate. If ISoP cannot verify your current membership, you will be charged the Non-member rate.

An acknowledgement with information will be e-mailed within one week of our receiving payment.

The course will start on 04 September at 08.30 through to 18.00 and continue on 05 September at 08.30 through to 17.00 and 06 September at 08.30 through to 17.00.