Mrs. Ms. Mr. Prof. Dr.
Last name: *
First Name
Company name: *
Function
Attending: *	November 14: (Conference) November 14 and 15 (Conference and Optional program)
Address:
Zip or Postal code:
City:
Country:
Telephone number:
Fax number:
Email: *
Optional program (Nov. 15) What is your preference? *	Option 1: Workshops (only morning) Option 2: Visit: Cultural Amsterdam or other cultural event Option 3: Free Golf (9/18 holes) , free equipment and free clinic! Bring your own golf shoes with you! Option 4: Not Applicable
SPECIAL Hotel arrangement
Special Dietary need:	Vegetarian Low Salt Diabetic Non-dairy Other? Pls fill out in the Remarks box.
Participating & Hotel stay	November 14: Registration Fee Euro 200, November 14: Registration Euro 200,- plus 1 night hotel (arriving on 13 Nov.); total Euro 270,- November 14 & 15: Registration Euro 200,- plus 2 nights hotel (Nov. 13 & 14); total Euro 340,-
Remarks
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Method of Payment	Bank transfer Receiving an Invoice
REGISTRATION button

Please transfer your Registration Fee and your Hotel accommendation cost (if applicable) after receiving our confirmation to:
ABN-AMRO BANK
Bank account: Qserve Consultancy BV
reference: “Qserve conference 2011"
Account nr.: 52.75.49.088
IBAN: NL29ABNA0527549088

Hampshire Golfhotel Waterland
BurgGolf Purmerend, Westerweg 60, 1445 AD Purmerend (greater Amsterdam)

T: +31 (0) 299  481606
F: +31 (0) 299  481697
www.burggolf.nl

The Hampshire Golfhotel Waterland is close to (any) public transport (train & bus). The organization team will pick you from  and you bring to the Airport "Schiphol", or train station Purmerend Weidevenne or bus station indicated!

Conditions:

Conference Fee: All participants must register and pay the registration Fee plus hotel accomendation cost after confirmation and upfront to the event.

This special registration fee for each participant is Euro 200,- of this fee which half will be donated to the program of Rotary International to establish a polio-free world; this is a joint effort with the Bill & Melinda Gates Foundation.
Registration Cancellation: no refund available of the confirmed registration. Only registered and confirmed attendees may participate in the conference.

Thank you very much for your Registration!

the Organization team