IV LATIN AMERICAN CONFERENCE ON BIOBANKS

REGISTRATION FORM Please use block capitals

SURNAME NAMES

ADDRESS CITY

ZIP/ POSTAL CODE PROVINCE/STATE COUNTRY

TELEPHONE FAX CELLULAR PHONE

E-MAIL

PROFESSIÓN

INSTITUTION / ORGANIZATION ADDRESS/COUNTRY

REGISTRATION DATA

Registration deadline: 08/29/08 September 4 September 5 and 6 September 4, 5 and 6

MEMBERS $100 $150 $200

NON-MEMBERS $200 $250 $340- U$S120

Discount deadline: 07/20/08 September 4 September 5 and 6 September 4, 5 and 6

MEMBERS $ 80 $120 $160

NON-MEMBERS $160 $200 $280- U$S 100

METHOD OF PAYMENT MEMBER YES ( ) NO ( )

Cash ð Check payable to CEMIC ð Credit cards ð

AMOUNT

CHECK Nº BANK

CREDIT CARDS

I hereby authorize to debit from my credit card the amount stated below

American Express ð VISA ð MASTER CARD ð

Card Number Security Code Month Year Amount

Expiration Date

Cardholder full name Cardholder signature

CHECKS

The registration form must be sent by mail or submitted personally to CEMIC. The check payable to CEMIC (in Argentine pesos) must be issued by an Argentine bank. In case of wire transfer and/or deposit (in US dollars), the operation must be done in a US bank.

The wire transfer or deposit confirmation must be sent by fax, e-mail or private courier. Otherwise, due receipt will not be issued and the registration will not be considered.

The organizing committee is not responsible for lost checks sent by ordinary mail. Private courier is strongly recommended.

Transfer data (US dollars):

J. P. MORGAN CHASE 270 Park Ave – 43rd floor NY – NY10017

Bank Account: CEMIC / ABA (or routing #): 021 000 021 / checking account: 949-1-425865

CREDIT CARD

The registration form must be sent by fax, e-mail to ANA FINOCHIETTO COMUNICACIONES () / (5411 4733-9270), or mail, or it may be submitted personally to CEMIC. The credit card data must be provided (credit card name, number, security code, expiration date, amount and signature).

CASH PAYMENT

Cash payments may be in Argentine pesos or in American dollars (in an amount equivalent to Argentine pesos). Cash payments must be done at CEMIC.

Time:10 am – 01 pm / 03 pm – 05 pm

Places:

CEMIC, C. Saavedra (Cashier) Galván 4102 – CABA (C1431FWO); phone (5411) 4546-8241/8244/8254

CEMIC, Central (Cashier) Av. Las Heras 2939 – CABA (C1425ASG); phone (5411) 4809-1922/23

REGISTRATION CANCELLATION:

Cancellation requests must be made in writing to ANA FINOCHIETTO COMUNICACIONES. Those received prior to 20 July 2008 will be fully refunded, except for $50 (Argentine pesos) for administrative costs. Cancellation requests received between July 20 and August 29 will receive a 50% refund of the registration, except for $50 (Argentine pesos) for administrative costs. No refunds will be made after that date.

Secretariat ANA FINOCHIETTO COMUNICACIONES. (5411) 4733-9270 /