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TOXINS 2024
PRECEPTORSHIP
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Printed Materials

(This information will appear on all printed materials)

Username

First Name(Required)

Last Name(Required)

Degree

MD

PhD

Other

Title(Required)

Specialty(Required)

Other Specialty(Required)

Subspecialty

Affiliation(Required)

Address 1(Required)

Address 2

City(Required)

State / Province / Region(Required)

ZIP / Postal Code(Required)

Country(Required)

Personal Information for Hotel

Full Name(Required)

(As it appears on your identification)

Hidden

Passport Number

Hidden

Passport Country of Issue

Hidden

Passport Expiration Date

MM slash DD slash YYYY

Hidden

Date of Birth

MM slash DD slash YYYY

Hidden

Nationality

Email(Required)

Phone(Required)

(Please include country code if applicable)

Cell Phone(Required)

(Please include country code if applicable)

Emergency Contact Name

Emergency Contact Phone

Emergency Contact Relationship?

Spouse

Parent

Child

Other

Will you bring a guest?(Required)

No

Yes

Relationship?(Required)

Spouse

Child

Other

Guest Full Name(Required)

Hidden

Pharmaceutical Employee

I am a Pharmaceutical Representative and not entitled to complimentary hotel accommodations.

Pharmaceutical Representative(Required)

I am not a Pharmaceutical Representative.

I am a Pharmaceutical Representative and not entitled to complimentary hotel accommodations.

Hotel Information

Room Preference

Single

Double

Hotel Arrival Date

MM slash DD slash YYYY

Hotel Time of Arrival

Hotel Departure Date

MM slash DD slash YYYY

Number of Nights

Special Requirements, Allergies

Hidden

Extended Stay(Required)

No

Yes

Credit Card Number(Required)

Expiration Month(Required)

Expiration Year(Required)

Security Code(Required)

Cardholder Name(Required)

Address(Required)

City(Required)

State / Province / Region(Required)

ZIP / Postal Code(Required)

Country(Required)

Flight Information

If booking travel on your own, please send itinerary once flights are booked to Rose Puleo at rose.puleo@neurotoxins.org. (Itinerary and receipts must be submitted in order to receive reimbursement)

Hidden

Berlin Arrival Date

MM slash DD slash YYYY

Hidden

Berlin Departure Date

MM slash DD slash YYYY

Hidden

Travel

INA will book my travel

Book my travel on own

Hidden

Seat Preference

Aisle

Middle

Window

Hidden

Frequent Flyer Number

Preferred Flight

Hidden

City of Departure

Hidden

Arrival Airline

Hidden

Arrival Flight Number

Hidden

Departure Airline

Hidden

Departure Flight Number

Second Choice

Hidden

City of Departure

Hidden

Arrival Airline

Hidden

Arrival Flight Number

Hidden

Departure Airline

Hidden

Departure Flight Number

Member Login

Username(Required)

Password(Required)

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TOXINS 2024

Abstract Submission (closed)
Conference Program
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Registration Information
TOXINS 2024 Registration
Venue & Housing Information

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