Registration Form
Family Name:
First Name:
Speciality:
Institution / Organization:
Mailing Address:
Email:
City:
Country:
State:
Zip
Telephone:
Fax:
Accompanying Person
Family Name:
First Name:

Registration Fees

Active Participant: USD 300 (Until Junuary 20th, 2010)
USD 350 (Late registration)
Accompanying Person: USD 60 (Until February 25th, 2010)
USD 70 (Late registration)
Gala Dinner: No. Of Person(s)
Total Amount: (USD)
I want to present a talk YES NO
Topic Title:

Please make bank drafts/transfer payable to: Egyptian Diabetes Center (EDC)
Personal Checks will not be accepted

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