The XXXIInd World Congress of the International Society of Hematology

Abstract Submission Form

Online Registration

Registration Information
Complete the fields and press the Submit button at the bottom of the page.
Required fields are marked with an asterisk *.

In case the on-line registration submission is not succeeded, please download

the Registration and Hotel Reservation Form, fill in the form and submit it by fax number 662 716-5978.

I.Personal Information

Please type your name and information

Title *	Dr. Mr. Mrs. Ms. Prof. Other

First Name *

Family Name *

Nationality*

Institute / Organization*

Position*

Department*

Address line 1*

Adress line 2

City

State

Postcode *

Country *

Telephone (inc. international code) *

FAX

Email *

Profile : (select all that apply)
Hematologist	Internist	Pharmacist
Pediatrician	Researcher / Scientist	Resident / student
Orthopedist	Laboratory personnel	Oncologist
Nurse	Other

II. Registration Fee

REGISTRATION FEE	Early-bird registration before 30 Apr 08	Regular registration 1 May - 15 Aug 08	Late registration 16 Aug - 15 Oct 08	Onsite
Physician / Researcher
ISH member	US$ 250	US$ 300	US$ 350	US$ 400
Non - member	US$ 350	US$ 400	US$ 450	US$ 500
*Resident / Nurse**	US$ 150	US$ 200	US$ 250	US$ 300
Accompanying Person	US$ 100	US$ 150	US$ 150	US$ 200

Total amount(1) US$:

* Verification letter from the head of unit must accompany with the Registration Form

Upload letter with this form:

III. Accompanying Person Detail

Accompanying Person Full Name:
Accompanying Person Full Name:
Accompanying Person Full Name:
Accompanying Person Full Name:
Accompanying Person Full Name:
Accompanying Person Full Name:
Accompanying Person Full Name:
Accompanying Person Full Name:
Accompanying Person Full Name:
Accompanying Person Full Name:

IV. Social Event (Please tick the appropriate box(es)

Opening Ceremony &Welcome Reception 19 Oct 08 (Free for all registered participants) person(s)

Gala Dinner 22 Oct 08 Ticket US$ 50 person(s)

Total amount (2) US$

Total US$

V. Mode of Payment

Credit card

I authorize the Organizing Committee of ISH 2008 to charge the total amount indicated above to the following credit card :

Master card VISA

Please note that only VISA Card and Master Card are accepted. The card number, the cardholder's name, the expiry date and the security code on card (which is the last three or four digit number appearing on certain card) on the signature panel must be indicated in the Registration Form.

VI. Credit Card Holder

Please type or write in block letters
Delegate: Dr. Mr. Mrs. Ms. Prof. Other

**First name :		**Last name :
Address:
*E-mail: