*First Name		*Family Name
*Title	(Ms, Mr.)	Functional Title
*E-mail
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*Institution
*Address
Address (cont.)
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State/Province
*Zip/Postal Code
*Country	Select one... Afghanistan Albania AlgeriaAndorraAngola Argentina Armenia AustraliaAustriaAzerbaijan Belarus BelgiumBosnia and Herzegovina Brazil BulgariaCanadaCape Verde Chile China Colombia Congo Costa Rica Côte d'Ivoire Croatia Cuba CyprusCzech Rep Dem. People's Rep. of Korea Dem. Rep. of The Congo DenmarkDomenican Republic Ecuador Egypt El Salvador Equatorial Guinea Estonia Ethiopia FinlandFranceGabon Gambia Georgia GermanyGhana GreeceGreenland Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Hong Kong, Spc Adm Reg of China Honduras HungaryIceland India Indonesia Iran Iraq IrelandIsrael ItalyJamaica JapanJordan KenyaKuwait Kyrgyzstan Latvia Lebanon Lesotho Liberia Liechtenstein Lithuania Luxembourg Macao, Spc Adm Reg of China Madagascar Malawi Mali MaltaMartinique Mauritania Mauritius Mexico Monaco Mongolia MoroccoMozambique Namibia Nepal Netherlands New Zealand Nicaragua Nigeria NorwayOman Pakistan Panama Paraguay Peru Philippines Poland Portugal Puerto Rico Qatar Rep. of Korea Rep. of Moldova Réunion Romania Russian FederationRwanda Saudi Arabia Senegal Serbia and Montenegro Seychelles Singapore Slovakia Slovenia Sri Lanka South Africa SpainSudan Suriname SwedenSwitzerlandSyrian Arab Republic Taiwan Tajikistan Thailand The form Yug Rep of Macedonia Timor-Leste Togo Tonga Trinidad and Tobago TunisiaTurkey Uganda Ukraine United Arab Emirates United KingdomUnited StatesUruguay Uzbekistan Venezuela Vietnam Yemen Zambia Zimbabwe Z....Other (specify in address lines)
*Work Phone
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Gender	M  F
Your age is
Vegetarian meals	Yes   No
Will you submit an abstract?	Yes   No
Title of abstract
*Registration	Select one... 280 euros

SPECIAL REQUESTS OR COMMENTS

Bank information:
You can pay your registration fees either by cheque made to the order of the European School of Haematology and sent to:
ESH, Centre Hayem, Hôpital Saint-Louis, 1 avenue Claude Vellefaux, 75475 Paris Cedex 10, France
or
by bank transfer made to the order of the European School of Haematology and sent to:
BNP Paribas, 156 avenue Parmentier, 75010 Paris, France
Bank code: 30004. Agency code: 01730.
Account number: 00010084349. Control key: 92.
IBAN: FR 76 3000 4017 3000 0100 8434 992
BIC: BNPAFRPPPBU

Payment: 
For payment by credit card, please choose the option credit card, then click "submit" and follow the instructions at the bottom.

Credit Card or  Bank Transfer

Please choose... Credit Card Bank Transfer  **All charges due on bank transfers have to be paid by the sender.     After submitting your registration, please forward a copy of the bank transfer by fax to: 0033 1 57 27 68 38.     Please put your name clearly on the transfer.

For payment by bank transfer please fill in your BIC / SWIFT code, in order to trace your payment:

CANCELLATION POLICY OF REGISTRATION FEE
In case of cancellation, up until one month prior to the beginning of the meeting, your registration fee will be reimbursed in full (less bank charges).
If the cancellation is notified between 1 and 30 days prior to the beginning of the meeting, 50% of the registration fee will be reimbursed (less bank charges).
Cancellations notified during the meeting will not be reimbursed.

ESH
Centre Hayem, Hôpital Saint-Louis
1 avenue Claude Vellefaux, 75475 Paris Cedex 10, France
Telephones: +33 1 57 27 68 43 / Fax +33 1 57 27 68 38
Email: celine.caudroit@univ-paris-diderot.fr