Registration form page 1 of 3

Always register online if you can via www.2014.excellence-in-diabetes.eu. If not an option, you may register for the Excellence in Diabetes by sending the Registration Form and your payment details to the Conference Organisers. From 28 February 2014 onwards registrations will be accepted only at the Conference Secretariat operating in the Conference Venue, on 28 February - 2 March 2014. Send your completed Registration Form to: The EiD 2014 Registration department Fax: +44 (0) 208 326 5726 Email: eid@2eic.com
Registration types and fees Full delegate Trainee / young investigator* Participant from a developing country* Participant from Gulf country Early Bird By 31 Jul 13 USD 400 USD 200 USD 200 USD 200 Early 30 Sept 13 USD 450 USD 250 USD 250 USD 250 Standard 31 Dec 13 USD 500 USD 300 USD 300 USD 300 Late 16 Feb 14 USD 600 USD 400 USD 400 USD 400 On-site 28 Feb-2 Mar 14 USD 700 USD 500 USD 500 USD 500

When you register, you will be charged the applicable fee on your registration date. Please note that the reduced registration fee will only apply for: trainees / young investigators, i.e. doctors and researchers under 35 years of age. To be considered for this category, please attach a proof of identity, such as a copy of an ID card or passport, that clearly indicates your birth date. participants from developing regions, as per the World Bank. To be considered for this category, please attach a letter of recommendation from your employer verifying your work place with full contact details. To check whether your country belongs to the developing regions, as per the World Bank website, please click on one of the following links, according to your location: EAST ASIA & PACIFIC (data.worldbank.org/region/EAP); EUROPE & CENTRAL ASIA (data.worldbank.org/region/ECA); LATIN AMERICA & CARRIBEAN (data.worldbank.org/region/LAC); MIDDLE EAST & NORTH AFRICA (data.worldbank. org/region/MNA); SOUTH ASIA (data.worldbank.org/region/SAS); SUB SAHARAN AFRICA (data.worldbank.org/region/SSA). Healthcare professionals from the Gulf countries are subsidised by the Qatar Diabetes Association. Tobe considered for this category, please attach a letter of recommendation from your employer verifying your work place. Gulf countries are defined as per the World Bank website: Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and United Arab Emirates.

Registration entitlements Participation in all scientific sessions Entrance to the exhibition area Participation in the opening ceremony Participation in the welcome reception Conference materials Coffee breaks Lunch breaks Certificate of attendance with CME credits

Full delegate p p p p p p p p

Trainee or young investigator p p p p p p p p

Participant from a developing country p p p p p p p p

Participant from a Gulf country p p p p p p p p

Payments. You can pay your manual registration by: 1. Complete the Billing Details Form and send it with your Registration Form 2. Make a bank transfer to the Conference Organiser (please send a copy of the receipt together with your Registration Form):
Banks Name: Beneficiarys Name Account number: IBAN: SWIFT/BIC: Conference Code: VAT No HSBC Bank Plc, 16 Kings Street, London WC2E 8JF E I Congresses & Communications UK Ltd. 70679686 GB93 MIDL 4005 1570 6796 86 MIDLGB22 EID2014 GB 943 8010 33

Cancellations and substitutions policy

$30 for written cancellations or alterations* received before 28 November 2013. Please note that an administrative fee will be applied on any cancellation of a completed registration. In the unfortunate event of a cancellation, we will endeavour to help you through the policy shown here below. Please note that all refunds will be processed two (2) months after the conclusion of the Conference. The size of the administrative fee depends on how close to the event the cancellation is made. For written cancellations or alterations*, administrative fee charges apply as follows: $80 for written cancellations or alterations* received from 29 November 2013 to 31 December 2013. 50% of the registration value for written cancellations received from 1 January 2014 to 31 January 2014. $80 for written alterations* received from 1 January 2014 to 31 January 2014. 100% of the registration value for written cancellations received after 31 January 2014. $110 for written alterations* received after 31 January 2014

*In case of alteration, a completed Registration form must be submitted for the new (i.e. the substituting) delegate.

Registration form page 2 of 3

What type of information took you to this registration form?
Please select all applicable by clicking in the corresponding boxes

Email from EiD, with a link + reminder to register My colleague or boss asked me to register Advertised link in a medical publication Google or other search engine Publicly displayed poster advertisement My medical association notified me

I was invited by an industry representative Information received at a conference Social media (Facebook, Twitter, etc.) Newsletter article or advertisement I already visited EiD 2013

Please use this registration form only if you cannot register online via www.2014.excellence-in-diabetes.eu This registration form is for 1 delegate only. All requested sections must be completed before you can register. Please use CAPITAL LETTERS only, and tick the boxes where appropriate. Submit your completed registration form to eid@2eic.com or via fax to +44 (0) 208 326 5726, with attention to The Registrations Department, EiC2 Ltd. About you (please click once in the text box first, then type your name with the computer keyboard) 1. Last name 2. First name 3. You are a... Male
Please select all applicable

Female

4. You are a... Doctor

Professor

Other

5. What is your current work role ? Diabetologist Endocrinologist General practitioner Ophthalmologist Internist Cardiologist Surgeon Neurologist Dietician Other medical specialist Psychologist Junior doctor Researcher/teacher Other

6. In what type of setting do you work ?

Please select all applicable

Primary care (or any outpatient clinic) Secondary care (general hospital) Tertiary care (specialised hospital) Private practice University Other (industry, social, government, etc.)

7. How many years of post-graduate training or work experience do you have within diabetes? Your contact details 8. Department 9. Organisation 10. Postal address 11. Post code 14. Email 12. City 15. Mobile 17. Do you need an invitation for a visa for Qatar ? Yes No 13. Country 16. Fax

Qatar grants tourist visas at border points for the nationals of more than 33 countries including USA, Canada, Iceland, West European countries, some East European countries, Japan, Singapore, Malaysia, Hong Kong, South Korea, Brunei, Australia and New Zealand, besides the nationals of the GCC countries. For details, please check http://english.mofa.gov.qa/details.cfm?id=93

Your safety is important to us. Please indicate a contact person in case of emergency 18. Last name 19. First name 20. Email 21. Mobile [+country code]

Registration form page 3 of 3

Contact person for billing and billing address 22. Last name 23. First name 24. Department 25. Organisation 26. Postal address 27. Post code 30. Email 33. You would like a... Receipt 28. City 31. Tel Invoice 29. Country 32 Fax

Important information. The Conference Organisers of the Excellence in Diabetes reserve the right at any time to change the programme or to cancel or postpone the Conference. In the event of cancellation or postponement, their liability is limited to refunding any registration fee already paid. The Conference Organisers will notify registered participants at the address shown on their registration form of any decision to cancel or postpone. The Conference Organisers strongly recommend attendees take out their own insurance against any losses arising from cancellation or postponement of the Conference or the inability of a participant to attend for any reason whatsoever, and they accept no liability for any loss or damage suffered by any participant or accompanying person or other person whatsoever. It should be noted that the data given in this form will not be disclosed to any third parties who are not directly involved in the organisation of the Excellence in Diabetes nor will it be publicised in any other way. I agree to the collection and processing of my personal data by EiC2, for the purpose of sending information materials (newsletters) in relation to conferences with similar topics, as well as promotional and advertising emails inaccordance with its advertising policy. 34. I do agree with the above statement about my personal data Yes No

I hereby confirm that I have read and understood the registration terms as well as the cancellation and substitution policy, which I accept without any reservations.

Date

Signature An original signature is required; no typing.