Belgian Brain Congress 2012

You can register for the Belgian Brain Congress 2012 online, just complete the form below. If you choose to pay via Credit Card, you will be redirected to Paypal where you'll be able to create an account and pay up. The amount varies depending on your category (see table below) and weither or not you register before the 1st september 2010 (at 00:00 Central European Time).

Your Category	Until Sept 30	Oct 1 and later	On site
Category A: Academic and MD	125€	150€	175€
Category B: Industry	200€	250€	300€
Category C: Resident and PhD below 30 years old	0€	0€	25€
Category D: Patients Association member	0€	0€	25€
Category E: Invited speakers, chairperson, organizers	0€	N/A	N/A

First Name:
Last Name:
Institution:
Department:
Address:
ZIP/Postal Code:
City:
Country:
Phone:
Fax:
Email:
Category:	Category A Category B Category C Category D Category E
Payment:	Credit Card (Through Paypal) Bank Transfer
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