Registration Form

International College of Angiology

Member, Council for International Organizations of Medical Sciences (CIOMS)

Contact Us

Executive Office:

International College of Angiology

161 Morin Drive

Jay, Vermont 05859-9283 USA

Tel: +802.988.4065

Fax: +802.988.4066

Email: ica@intlcollegeofangiology.org

Congress participants from the Host Country of Indonesia are requested to contact and register with:

Haryono Tours & Travel

Jl. Kebon Sirh Raya 9K, Jakarta 10340, INDONESIA

Phone: +62-21-3920808 (hunting)

Fax: +62-21-3140891

E-mail: mice-Jakarta@haryonotours.com

Contact: Aran/Stefania

Registration - Indonesian Participants

57th Annual World Congress

International College of Angiology

in conjunction with the

7th National Symposium on Vascular Medicine

Jakarta, Indonesia

October 2-4, 2015

*This fee is NOT applicable to Oral, Poster or Video Presentations. Nurses, PA's, RVT's, and Allied Healthcare Personnel MUST provide proof confirming their status.

** Requires a verification letter from the registrant's Department Head/Chair. STUDENTS MUST provide a copy of their valid Student Card.

Associate Fellows of the ICA, in good standing, ARE NOT REQUIRED TO PAY A REGISTRATION FEE as part of their membership benefit. (This only applies to the first 3 years of membership. Thereafter, the full registration fee applies).

Registration Cancellation Policy

A written request must be received no later than 15 August 2015, less a (USD) $50 administrative fee. There will be a 50% processing fee for all cancellationsreceived after 15 August 2015 and before 15 September 2015. Fees are non-refundable after 15 September 2015.

Registration Fee includes: Access to the scientific sessions, the industry exhibits and congress documents (Final Program, Certificate of Attendance, Congress Bag, Congress Badge, and all official congress events.

Accompanying Spouse/Person(s):

Surname/Family Name: *

Specialty: *

Fax:

Mobile Phone: *

Secondary Email:

Zip/Postal Code: *

Country: *

State/Province *

City: *

Street/Mailing Address *

Department:

Institution:

Title: *

First Name/Middle Initial(s): *

Email: *

Registration Category *

ICA Fellow, Associate Fellow, Member, Affiliate Member

All Other Non-Fellows

RN/PA/RVT/Allied Medical Sciences*

Fellow/Resident/Intern**

Student**

Telephone: *

Please complete this section accurately. The information you provide will allow us to correspond with you efficiently. Fields marked with (*) are required.

Participant's Identification

The REGISTRATION FORM below is ONLY for those Congress participants from outside of the Host Country of Indonesia

Please complete the form below and the "SUBMIT" button, or PRINT, fill out in BLOCK LETTERS and FAX or AIRMAIL together with payment to the Executive Office of the International College of Angiology at:

INTERNATIONAL COLLEGE OF ANGIOLOGY

57th ANNUAL WORLD CONGRESS 2015

161 Morin Drive, Jay, Vermont 05859-9283 USA

Tel: +1.802.988.4065

Fax: +1.802.988.4066

Registration Form - Participants Outside of the Host Country of Indonesia