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NEW PARTICIPANT

 

Participant Information

 

For new laboratories joining NordiQC

 Accounting information **

 Hospital *

 Hospital

 Departm./laboratory

 Institution/comp.

 Address *

 Name/Attention

 Address (ct.)

 Address

 Zip and City *

 Zip, City

 

 Country *

 Country

   

 Purchase order /

 Payment code no.

   

 Payer e-mail add.

 Names:

 

 

 

 Contact person 1 *
 (=Name on slide mails)

     E-mail 1*

 Contact person 2

     E-mail 2

 Contact person 3

     E-mail 3

 Contact person 4

     E-mail 4


 Participation:

 Tick boxes ***

 

 IHC=Immunohistochemistry

 ISH=in situ hybridization

 

  General module:                   Yes No To ensure the communication it is recommended to indicate at least 3 e-mail addresses.
 Breast cancer IHC module: Yes No
 HER-2 ISH module:             Yes No
 Comments ****

 UIN/UID/EAN/VAT
 number:**

* Fields required. Name of Contact person 1 is used for slide mailing.
 

** Information that may be requested by your accounting manager or sponsor. Data indicated in these fields are merged into the invoice, which is e-mailed to the payer e-mail address or (if this is not indicated) to contact person 1.

In case of sponsorship, you must specify in Comments' field which module(s) the sponsorship covers and who should be invoiced for unsponsored participation in a module.

NB! If you have a sponsorship for the Breast cancer module, and also participate in the General module without a sponsorship, please write the Accounting information for the General module only, and just specify the name of your sponsor in the Comments' field.
 

*** Tick Yes or No in the boxes to indicate which module(s) you wish to participate in. See the fees on Subscription.
 

**** e.g., Special subscription terms. If sponsored participation, you must indicate company, module(s) and year.
Please also fill out relevant fields in the Accounting information.
Need support? - Contact the Administrator

Last update  02-01-2012