REGISTRATION FORM

Family name: Dr./Prof. Name
Profession Discipline
Place and date of birth
Address City Country
Zip Code Telephone Fax
e-mail

Will take part in the Symposium with n° persons (subscription C.C.O.S. for 2011 € 200,00 each)
		€

Students in Dentistry or Medicine and Surgery (subscription C.C.O.S. for 2011 € 90,00) University matriculation number
		€
		AMOUNT €


Will be present at the Cocktail offered by the Government of the Principality of Monaco on Friday 4th November 2011 at 7.30 p.m.

Attached please find bank draft for the amount of €
Bank transfer to the Centro Culturale Odontostomatologico, Torino, Italia, Banca Popolare di Novara, n° 070 Branch Office, Torino, Italia, via XX Settembre 44, IBAN: IT86Y0560801000 00000000 3283
Informativa / Tutela Privacy I certify that I know the privacy statement as per art. 13 of D. Leg. 196/03 and the rights set out in art. 7 of D. Leg. 196/03 and I give the CCOS my consent to treat my personal data also electronically and/or through automated tools both in Italy and abroad for the purposes relating to the registration to the CCOS provided they are concerning the institutional tasks of the Scientific Society. I give my consent to use my personal data in relation to association services that may be provided through companies and/or third parties in the context of the activities of the Scientific Society. I further give my consent to any form of processing including modification, integration and deletion of the data. I take note that the controller of my personal data has put in place suitable measures to protect and to keep my personal data as confidential.

XXIII	International
	Odontostomatologic Congress
MONTE-CARLO 4-5 November 2011