Galén Symposion

Registration

Personal data

* Gender

Pre-nominal letters

* Given name(s)

* Family name(s)

Post-nominal title(s)

Work data

* Workplace

Department

Specialization

Contact details

* Email

Mobile phone

Phone

Fax

Address

Address type

Street

City

ZIP

Country

Account

Identification Number

VAT number

Invoicing address

* Company

* Street

* City

* ZIP

* Country

Correspondence address

Company / Name

Street

City

ZIP

Country

I agree to the processing of personal data

By submitting this form I agree with the use and holding of my personal data by company GALÉN-SYMPOSION s.r.o., Praha - Vinohrady, Vinohradská 343/6 in accordance with the Czech personal information protection act Nr. 101/2000 Sb.
Please note that after submitting this form you will receive your login and password by email. Please use these to log-in and view and edit your personal details, abstracts and payment information.

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