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1ST IPCC KIT HEL December 13-15 O REGISTRATION FORM CONGRESS VENUE KAMINSKI HOTEL WAS TYROL GOLDBERG 2012 1ST INTERNATIONAL WINTER CONSENSUS CONFERENCE OF DERMATOLOGY Please complete all sections

Full Name/Middle Name: Date of Birth: Country: State of Residence: Birthplace of Parents (if parents are neither of the above) Birthplace of Grandparents (if parents are neither of the above) Where did the baby come from? (If the baby is from outside the US or Canada, please provide the country where the parents are living) Date of Birth: Gender: Male Female Age: Years of Education in Previous Position: Years of Education in Current Position: Occupation (if any): (All are required. You can choose to have only one or both listed) Occupation (If Only One): Position Held: If any, Where did you previously serve on the IPCC? (If more than one, please select “Last Position” under each) Position Held (if more than one) Occupation (If Both) Position Held (If Both) Is applicable, Other: Other If this is the first time you are registering with this event, please allow adequate time in order to complete the registration form and ensure that you have made all necessary arrangements. Please be aware that it may take several days for the registration form to be sent to you. You can also send your request for instructions to all delegates by email, and ask them to confirm your registration. Click here to register for the Conference. Registration is NOT required to attend the Scientific Meeting. However, attending the Scientific Meeting is highly recommended, because all the meetings will be presented in a scientific presentation format. Attendees of a session will still be able to view the presentations. Note: The Scientific Meeting will NOT be held in Geneva, though presentations will be given in Geneva. If you are registering as an individual, please do not include any contact information on your registration form. To confirm your registration to attend the Conference in a personal capacity and to receive your confirmation e-mail, you will be required to complete the details provided below. If you would like to enter the Conference in another capacity (as a participant, delegate, or official), please select the appropriate option below. Confirmed By: If you received your confirmation e-mail prior to 16th January, you are considered to have confirmed your registration. If you received your confirmation e-mail after 16th January, you have not confirmation to confirm your registration. Please confirm your request for inclusion to attend the 2014 IPCC Conference, in the interest of maintaining the highest standards of conduct.

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