EFMD – EURAM research Leadership Programme – Cycle 7 EFMD – EURAM research Leadership Programme Brussels, October & December 2017 Personal information:Title*DrMrMrsMsProfName* First Last Job Title*Company/Institution*Address* Street Address Address Line 2 City ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Email* Phone*Purchase OrderAffiliated to VAT ?*YesNoVAT number*My portraitPlease attach your photo in JPG format (full face portrait; 1MB max.). The photo will be added to the participants' list to facilitate networking.Accepted file types: jpg.Membership:Membership Status*EFMD/EURAM Full MemberNon-memberRegistration Fee:Early Bird Fee until 13 June 2017:as EFMD/ERAM Full Member Price: 3.500,00 € as Non-member Price: 4.000,00 € Total price (VAT included):VAT 0,00 € TOTAL 0,00 € These fees cover attendance to the meeting, documentation, meals and refreshments, but NOT hotel accommodations. Payment method*Please note that we cannot accept Debit Cards Bank TransferCredit CardCANCELLATION POLICY: Cancellations must be confirmed in writing. If we receive notice of your withdrawal before 25 August 2017, a cancellation administrative fee of 75€ + 21% VAT will be charged. Thereafter, we regret that we are unable to refund any fees. However, in such cases, substitutes are welcome at no extra cost as long as EFMD receives notification of the name, title and address of the substitute.Catering:I will join the dinner on Monday 2 October 2017*YesNoI am allergic toalmondsblueberriesboletus mushroomchivesfigshazelnutsshellfishotherif 'other', please specify:*Dietary requirementsno dairy productsno fishno glutenno meatno nutsno porkno shellfishveganvegetarianotherPlease specify*General:I agree with the terms and general conditions stated on your website.* Yes I declare that all the information stated above is accurate, including allergies and dietary requirements.* Yes I authorise EFMD to use all information communicated within the legal framework of its activities.* Yes I agree to receive an e-mail newsletter and other communication material from EFMD.* I can unsubscribe or update my preferences at any time.YesNoTechnical informationRegistration date Your unique IDOrganiser email Event referenceHotel registration form October Hotel registration form December NameThis field is for validation purposes and should be left unchanged.