Zeroseicongressi srl | Template ISTA 2025
16682
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Template ISTA 2025

Title (*)
[text* Title]

First Name (*)
[text* Nome]

Last Name (*)
[text* Cognome]

Email (*)
[email* email]

Phone (*)
[tel* tel-674]

Affilitation [text entediappartenenza]

Speciality
[select Speciality first_as_label “please select” “Surgeon” “Engineer” “Scientist” “Clinician” “Allied Health Worker” “Industry”]

Attending Welcome Reception(*) (please indicate number of people) [text* numeropersone]

Address (*)[text* indirizzo]

City (*)
[text* Comune]

ZIP/Postal Code (*)
[text* CAP]

Country (*)
[text* Country]

Dietary requirements [text dieta]

Congress Registration

ISTA Membership

PULSANTE OPZIONE

Gala Dinner Villa Miani

PULSANTE OPZIONE

Partner Programme

PULSANTE OPZIONE

Type of payment (*)

[radio paymenttype use_label_element “Bank transfer issued to Zeroseicongressi S.r.l. (bank transfer expenses to be charged to the payer)
IBAN: IT89G0832703239000000004232 ; BIC/SWIFT: ROMAITRR” “Credit card (only VISA or Mastercard)”]

[acceptance accettocondizioni] I agree to the processing of my personal data. (*)

[submit “SUBMIT REQUEST”]