2019 AHRMIO Annual Conference - Registration FormStep 1 of 333%Personal information:Name* DrMrMrsMsProf. Title First Last Job Title*Company/Institution*Address* Street Address City State / Province / Region ZIP / Postal Code Country AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Email* Phone (Int'l)Purchase orderMy portraitAccepted file types: jpg.Please attach your photo in JPG format (full face portrait; 1MB max.). The photo will be added to the participants' list to facilitate networking.Registration status:I am:*Member or Advisory MemberFounding memberNon-memberSponsorSpeakerAHRMIO staffEFMD staffHost staffPrice:(early-bird fees applied)(normal fees applied)as Member or Advisory Member Price: 792,00 € as Founding member Price: 713,00 € as Non-member Price: 1.584,00 € as Sponsor Price: 792,00 € Voucher Lodging & Catering:Do you need a hotel room?*yesnoThe conference hotel is the Boston Hotel Buckminster. Rooms have been pre-reserved for conference participants however you are responsible for booking your own accommodation (see the ""accommodation" section on the main event page for booking details and reference code)Welcome Dinner*yesnoConference Dinner*yesnoI am allergic toalmondsblueberriesboletus mushroomchivesfigshazelnutsshellfishother(CTRL-Click for multiple)Please specify 'other':*Dietary requirementsno dairy productsno fishno glutenno meatno nutsno porkno shellfishveganvegetarianotherPlease specify 'other':* Accompanying personAccompanying person social events?noyesName Dr.Mr.Mrs.Ms.Prof. Title First Last Accompanying person cateringWelcome dinner*yesnoConference dinner*yesnoWelcome dinner extra person Price: 55,00 € Conference dinner extra person Price: 70,00 € Person allergic toalmondsblueberriesboletus mushroomchivesfigshazelnutsshellfishotherPlease specify 'other':*Person's dietary requirementsno dairy productsno fishno glutenno meatno nutsno porkno shellfishveganvegetarianotherPlease specify 'other':* Amount due:Total 0,00 € Payment method*Bank transferCredit CardPlease wait for our financial department to issue an invoice.Credit CardAmerican ExpressMasterCardVisa Card Number Month010203040506070809101112 Year20192020202120222023202420252026202720282029203020312032203320342035203620372038 Expiration Date Security Code Cardholder Name Your credit card information is passed directly from your browser to Stripe over a secure connection.General:The fees cover attendance to the meeting, documentation, meals and refreshments, but NOT hotel accommodations.CANCELLATION POLICY: Cancellations must be confirmed in writing. If AHRMIO receives notice of your withdrawal before 15/08, a cancellation administrative fee of (75€ + VAT) will be charged. Thereafter, we regret that we are unable to refund any fees. However, in such cases substitutes are welcome at no extra cost as long as AHRMIO receives notification of the name, title and address of the substitute. Also note that if we haven't received your payment (or proof of payment) before the list is printed (on 08/09), your contact details will not be included in that list.Your remarksTechnical information:Date Date Format: MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.