Swiss School of Public Health +

¦ E ¦ D ¦ F ¦ I ¦

University of Basel + University of Bern + University of Zurich
University of Geneva + University of Lausanne + University of Neuchâtel + University of Lugano


Business address	Surname		First name
	Organisation
	Street/No.
	Post code / Town
	Country
	Phone		Fax
	Mobile phone		E-mail

Private address	Street/No.
	Post code / Town
	Country
	Date of birth		Sex	m f
	Profession
	Last diploma obtained
	Present position

SSPH+ student	I am enrolled in one of the SSPH+ programmes: yes no
	If yes, please indicate the name of the programme:

Course(s) chosen	From 9 August to 13 August 2010	From 16 August to 20 August 2010
	First week 1 2 3 4	Second week 5 6 7 8
	Title		Title
	If the chosen course is full, my second choice would be:
	1 2 3 4 5 6 7 8

Costs	I will pay the following amount (by 15 June 2010 the latest)
	Registration fee as external participant CHF 1'200.- (per course)
	Registration fee as SSPH+ student CHF 1'000.- (per course)
	Registration fee			CHF

	Invoice needed			yes no

Payment	By bank transfer in favour of the bank: Banca UBS SA CH-6900 Lugano Account no. : 247-587031.01Y Code SWIFT/BIC UBSWCHZH69A IBAN CH460024724758703101Y As reference include « Summer School SSPH+ » and your name.	By postal transfer in favour of the bank: Banca UBS SA CH-6900 Lugano Current postal account number : 80-2-2 In favour of the account : 247-587031.01Y As reference include « Summer School SSPH+» and your name.
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