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JAVASCRIPT IS REQUIRED FOR THE FOLLOWING FORM!!!
Salutation
-- Choose --
Mr
Ms
Mrs
Title (Degree - MUDr., Professor, etc.)
First name
Last name
Post-nominal letters (Ph.D., M.Sc. etc.)
Organisation
Department
Street, Number
Town/City
Post/ZIP code
Country
-- Choose --
Afghanistan
Aland Islands
Albania
Algeria
American Samoa
Virgin Islands, U.S.
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belgium
Belize
Belarus
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Virgin Islands, British
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cook Islands
Curaçao
Chad
Montenegro
Czech Republic
China
Denmark
Dominica
Dominican Republic
Djibouti
Egypt
Ecuador
Eritrea
Estonia
Ethiopia
Faroe Islands
Falkland Islands (Malvinas)
Fiji
Philippines
Finland
France
French Guiana
French Southern Territories
French Polynesia
Gabon
Gambia
Ghana
Gibraltar
Grenada
Greenland
Georgia
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong
Chile
Croatia
India
Indonesia
Iraq
Iran
Ireland
Iceland
Italy
Israel
Jamaica
Japan
Yemen
Jersey
South Africa
South Georgia and the South Sandwich
Jordan
Cayman Islands
Cambodia
Cameroon
Canada
Cape Verde
Qatar
Kazakhstan
Kenya
Kiribati
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Republic of Korea
Korea, Democratic Peoples Republic of
Costa Rica
Cuba
Kuwait
Cyprus
Kyrgyzstan
Lao Peoples Democratic Republic
Lesotho
Lebanon
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Latvia
Luxembourg
Macao
Madagascar
Hungary
Macedonia
Malaysia
Malawi
Maldives
Mali
Malta
Morocco
Marshall Islands
Martinique
Mauritius
Mauritania
Mayotte
United States Minor Outlying Islands
Mexico
Micronesia, Federated States of
Moldova, Republic of
Monaco
Mongolia
Montserrat
Mozambique
Myanmar
Namibia
Nauru
Germany
Nepal
Niger
Nigeria
Nicaragua
Niue
Netherlands Antilles
Netherlands
Norfolk Island
Norway
New Caledonia
New Zealand
Oman
Isle of Man
Pakistan
Palau
Palestinian Territory, Occupied
Panama
Papua New Guinea
Paraguay
Peru
Pitcairn
Côte dIvoire
Poland
Puerto Rico
Portugal
Austria
Réunion
Equatorial Guinea
Romania
Russian Federation
Rwanda
Greece
Saint Barthélemy
Saint Pierre and Miquelon
El Salvador
Samoa
San Marino
Saudi Arabia
Senegal
Northern Mariana Islands
Seychelles
Sierra Leone
Singapore
Sint Maarten (Dutch part)
Slovakia
Slovenia
Somalia
South Sudan
United Arab Emirates
United Kingdom
United States
Serbia
Sri Lanka
Central African Republic
Sudan
Suriname
Svalbard and Jan Mayen
Saint Helena
Saint Lucia
Saint Kitts and Nevis
Saint Martin (French part)
Holy See (Vatican City State)
Sao Tome and Principe
Saint Vincent and the Grenadines
Swaziland
Syrian Arab Republic
Solomon Islands
Spain
Sweden
Switzerland
Tajikistan
Tanzania, United Republic of
Thailand
Taiwan, Province of China
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
Uruguay
Uzbekistan
Christmas Island
Vanuatu
Venezuela
Viet Nam
Timor-Leste
Wallis and Futuna
Zambia
Western Sahara
Zimbabwe
Phone
E-mail
Different invoicing address
Organisation
Street, Number
Town/City
Post/ZIP code
Country
-- Choose --
Afghanistan
Aland Islands
Albania
Algeria
American Samoa
Virgin Islands, U.S.
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belgium
Belize
Belarus
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Virgin Islands, British
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cook Islands
Curaçao
Chad
Montenegro
Czech Republic
China
Denmark
Dominica
Dominican Republic
Djibouti
Egypt
Ecuador
Eritrea
Estonia
Ethiopia
Faroe Islands
Falkland Islands (Malvinas)
Fiji
Philippines
Finland
France
French Guiana
French Southern Territories
French Polynesia
Gabon
Gambia
Ghana
Gibraltar
Grenada
Greenland
Georgia
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong
Chile
Croatia
India
Indonesia
Iraq
Iran
Ireland
Iceland
Italy
Israel
Jamaica
Japan
Yemen
Jersey
South Africa
South Georgia and the South Sandwich
Jordan
Cayman Islands
Cambodia
Cameroon
Canada
Cape Verde
Qatar
Kazakhstan
Kenya
Kiribati
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Republic of Korea
Korea, Democratic Peoples Republic of
Costa Rica
Cuba
Kuwait
Cyprus
Kyrgyzstan
Lao Peoples Democratic Republic
Lesotho
Lebanon
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Latvia
Luxembourg
Macao
Madagascar
Hungary
Macedonia
Malaysia
Malawi
Maldives
Mali
Malta
Morocco
Marshall Islands
Martinique
Mauritius
Mauritania
Mayotte
United States Minor Outlying Islands
Mexico
Micronesia, Federated States of
Moldova, Republic of
Monaco
Mongolia
Montserrat
Mozambique
Myanmar
Namibia
Nauru
Germany
Nepal
Niger
Nigeria
Nicaragua
Niue
Netherlands Antilles
Netherlands
Norfolk Island
Norway
New Caledonia
New Zealand
Oman
Isle of Man
Pakistan
Palau
Palestinian Territory, Occupied
Panama
Papua New Guinea
Paraguay
Peru
Pitcairn
Côte dIvoire
Poland
Puerto Rico
Portugal
Austria
Réunion
Equatorial Guinea
Romania
Russian Federation
Rwanda
Greece
Saint Barthélemy
Saint Pierre and Miquelon
El Salvador
Samoa
San Marino
Saudi Arabia
Senegal
Northern Mariana Islands
Seychelles
Sierra Leone
Singapore
Sint Maarten (Dutch part)
Slovakia
Slovenia
Somalia
South Sudan
United Arab Emirates
United Kingdom
United States
Serbia
Sri Lanka
Central African Republic
Sudan
Suriname
Svalbard and Jan Mayen
Saint Helena
Saint Lucia
Saint Kitts and Nevis
Saint Martin (French part)
Holy See (Vatican City State)
Sao Tome and Principe
Saint Vincent and the Grenadines
Swaziland
Syrian Arab Republic
Solomon Islands
Spain
Sweden
Switzerland
Tajikistan
Tanzania, United Republic of
Thailand
Taiwan, Province of China
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
Uruguay
Uzbekistan
Christmas Island
Vanuatu
Venezuela
Viet Nam
Timor-Leste
Wallis and Futuna
Zambia
Western Sahara
Zimbabwe
Company identification number
VAT number / Tax ID
I agree with the use and holding of my personal data connected to my participation at the HEMATOLOGIE 2024 by company Meritis s.r.o., Obrovského 644, 141 00 Praha 4 - Spořilov in accordance with the Czech personal information protection act 101/2000 Sb.