fs23.formsite.com
Open in
urlscan Pro
44.218.67.240
Public Scan
URL:
https://fs23.formsite.com/GYLA1E/5lfedhu6ux/index
Submission: On September 05 via manual from US — Scanned from DE
Submission: On September 05 via manual from US — Scanned from DE
Form analysis 1 forms found in the DOM
POST https://fs23.formsite.com/res/submit
<form method="post" id="FSForm" action="https://fs23.formsite.com/res/submit" enctype="application/x-www-form-urlencoded" onsubmit="return Vromansys.Form.processSubmit(this);">
<div style="display:none">
<input type="hidden" name="GenId" value="1JLVItpZHogYBIuW">
<input type="hidden" name="LocId" value="GYLA1E/5lfedhu6ux">
<input type="hidden" name="EParam" value="AT1kKIiyxDwjf6UwFcKBhKeLTfEDMMCueWDliq5fkx2wLw9mI5o8dMxv2u6QZQ-iTp-CXziEO4C9k_12lAouAL1Dh51X5C-oFzpUCZwnDno">
<input type="hidden" name="ElapsedTime" id="ElapsedTime" value="0">
<input type="hidden" name="Referrer" id="Referrer" value="">
<input type="text" name="subject_line" id="subject_line" autocomplete="off"><label for="subject_line">subject_line</label>
</div>
<!-- BEGIN_ITEMS -->
<div class="form_table">
<div class="clear"></div>
<div id="q45" class="q full_width">
<a class="item_anchor" name="ItemAnchor0"></a>
<div class="segment_header"
style="width:auto;text-align:Left;background-repeat:repeat;background-color:transparent;background-image:url("/images/stock/2015/BusinessAndTechnology/Business42.jpg");background-size: auto;background-position: 0% 0%;">
<h1 style="font-size:36px;padding-bottom:20px;padding-top:20px;background-color:rgba(0, 0, 0, 0.31)">2nd Annual European Medical Device and Diagnostic Reimbursement and Market Access Conference | 25th-26th October 2023 | Steigenberger Airport
Hotel Berlin, Germany</h1>
</div>
</div>
<div class="clear"></div>
<div id="q26" class="q full_width">
<a class="item_anchor" name="ItemAnchor1"></a>
<div class="segment_header" style="background:#000080;width:auto;text-align:Left;">
<h1 style="font-size:24px;padding-bottom:20px;padding-top:20px;">Attendee Details</h1>
</div>
</div>
<div class="clear"></div>
<div id="q49" class="q required">
<a class="item_anchor" name="ItemAnchor2"></a>
<label class="question top_question" for="RESULT_TextField-2">First Name <b class="icon_required">*</b></label>
<input type="text" name="RESULT_TextField-2" class="text_field" id="RESULT_TextField-2" size="23" value="">
</div>
<div id="q50" class="q required">
<a class="item_anchor" name="ItemAnchor3"></a>
<label class="question top_question" for="RESULT_TextField-3">Last Name <b class="icon_required">*</b></label>
<input type="text" name="RESULT_TextField-3" class="text_field" id="RESULT_TextField-3" size="23" value="">
</div>
<div class="clear"></div>
<div id="q58" class="q required">
<a class="item_anchor" name="ItemAnchor4"></a>
<label class="question top_question" for="RESULT_TextField-4">Email Address <b class="icon_required">*</b></label>
<input type="email" name="RESULT_TextField-4" class="text_field" id="RESULT_TextField-4" size="54" value="">
<div class="clear" style="padding:1px"></div>
<label class="question top_question" for="CONFIRM_TextField-4">Confirm Email Address <b class="icon_required">*</b></label>
<input type="email" name="CONFIRM_TextField-4" class="text_field" id="CONFIRM_TextField-4" size="54" value="">
</div>
<div class="clear"></div>
<div id="q79" class="q required">
<a class="item_anchor" name="ItemAnchor5"></a>
<label class="question top_question" for="RESULT_TextField-5">Mobile Number <b class="icon_required">*</b></label>
<input type="text" name="RESULT_TextField-5" class="text_field number_field" id="RESULT_TextField-5" size="25" value="">
</div>
<div class="clear"></div>
<div id="q59" class="q required">
<a class="item_anchor" name="ItemAnchor6"></a>
<label class="question top_question" for="RESULT_TextField-6">Job Title <b class="icon_required">*</b></label>
<input type="text" name="RESULT_TextField-6" class="text_field" id="RESULT_TextField-6" size="25" value="">
</div>
<div class="clear"></div>
<div id="q112" class="q required">
<a class="item_anchor" name="ItemAnchor7"></a>
<label class="question top_question" for="RESULT_RadioButton-7">Booking Contact <b class="icon_required">*</b></label>
<select id="RESULT_RadioButton-7" name="RESULT_RadioButton-7" class="drop_down">
<option></option>
<option value="Radio-0" selected="">Rachel D.</option>
</select>
</div>
<div class="clear"></div>
<div id="q25" class="q full_width">
<a class="item_anchor" name="ItemAnchor8"></a>
<div class="segment_header" style="background:#000080;width:auto;text-align:Left;">
<h1 style="font-size:24px;padding-bottom:20px;padding-top:20px;">Company Details</h1>
</div>
</div>
<div class="clear"></div>
<div id="q1" class="q required">
<a class="item_anchor" name="ItemAnchor9"></a>
<label class="question top_question" for="RESULT_TextField-9">Name Of Organization <b class="icon_required">*</b></label>
<input type="text" name="RESULT_TextField-9" class="text_field" id="RESULT_TextField-9" size="52" value="">
</div>
<div class="clear"></div>
<div id="q5" class="q required">
<a class="item_anchor" name="ItemAnchor10"></a>
<label class="question top_question" for="RESULT_TextField-10">City <b class="icon_required">*</b></label>
<input type="text" name="RESULT_TextField-10" class="text_field" id="RESULT_TextField-10" size="52" value="">
</div>
<div class="clear"></div>
<div id="q10" class="q required">
<a class="item_anchor" name="ItemAnchor11"></a>
<label class="question top_question" for="RESULT_RadioButton-11">Country <b class="icon_required">*</b></label>
<select id="RESULT_RadioButton-11" name="RESULT_RadioButton-11" class="drop_down">
<option></option>
<option value="Radio-0">Afghanistan</option>
<option value="Radio-1">Albania</option>
<option value="Radio-2">Algeria</option>
<option value="Radio-3">Andorra</option>
<option value="Radio-4">Angola</option>
<option value="Radio-5">Antigua and Barbuda</option>
<option value="Radio-6">Argentina</option>
<option value="Radio-7">Armenia</option>
<option value="Radio-8">Aruba</option>
<option value="Radio-9">Australia</option>
<option value="Radio-10">Austria</option>
<option value="Radio-11">Azerbaijan</option>
<option value="Radio-12">Bahamas, The</option>
<option value="Radio-13">Bahrain</option>
<option value="Radio-14">Bangladesh</option>
<option value="Radio-15">Barbados</option>
<option value="Radio-16">Belarus</option>
<option value="Radio-17">Belgium</option>
<option value="Radio-18">Belize</option>
<option value="Radio-19">Benin</option>
<option value="Radio-20">Bhutan</option>
<option value="Radio-21">Bolivia</option>
<option value="Radio-22">Bosnia and Herzegovina</option>
<option value="Radio-23">Botswana</option>
<option value="Radio-24">Brazil</option>
<option value="Radio-25">Brunei</option>
<option value="Radio-26">Bulgaria</option>
<option value="Radio-27">Burkina Faso</option>
<option value="Radio-28">Burma</option>
<option value="Radio-29">Burundi</option>
<option value="Radio-30">Cambodia</option>
<option value="Radio-31">Cameroon</option>
<option value="Radio-32">Canada</option>
<option value="Radio-33">Cabo Verde</option>
<option value="Radio-34">Central African Republic</option>
<option value="Radio-35">Chad</option>
<option value="Radio-36">Chile</option>
<option value="Radio-37">China</option>
<option value="Radio-38">Colombia</option>
<option value="Radio-39">Comoros</option>
<option value="Radio-40">Congo, Democratic Republic of the</option>
<option value="Radio-41">Congo, Republic of the</option>
<option value="Radio-42">Costa Rica</option>
<option value="Radio-43">Cote d'Ivoire</option>
<option value="Radio-44">Croatia</option>
<option value="Radio-45">Cuba</option>
<option value="Radio-46">Curacao</option>
<option value="Radio-47">Cyprus</option>
<option value="Radio-48">Czechia</option>
<option value="Radio-49">Denmark</option>
<option value="Radio-50">Djibouti</option>
<option value="Radio-51">Dominica</option>
<option value="Radio-52">Dominican Republic</option>
<option value="Radio-53">East Timor</option>
<option value="Radio-54">Ecuador</option>
<option value="Radio-55">Egypt</option>
<option value="Radio-56">El Salvador</option>
<option value="Radio-57">Equatorial Guinea</option>
<option value="Radio-58">Eritrea</option>
<option value="Radio-59">Estonia</option>
<option value="Radio-60">Ethiopia</option>
<option value="Radio-61">Fiji</option>
<option value="Radio-62">Finland</option>
<option value="Radio-63">France</option>
<option value="Radio-64">Gabon</option>
<option value="Radio-65">Gambia, The</option>
<option value="Radio-66">Georgia</option>
<option value="Radio-67">Germany</option>
<option value="Radio-68">Ghana</option>
<option value="Radio-69">Greece</option>
<option value="Radio-70">Grenada</option>
<option value="Radio-71">Guatemala</option>
<option value="Radio-72">Guinea</option>
<option value="Radio-73">Guinea-Bissau</option>
<option value="Radio-74">Guyana</option>
<option value="Radio-75">Haiti</option>
<option value="Radio-76">Holy See</option>
<option value="Radio-77">Honduras</option>
<option value="Radio-78">Hong Kong</option>
<option value="Radio-79">Hungary</option>
<option value="Radio-80">Iceland</option>
<option value="Radio-81">India</option>
<option value="Radio-82">Indonesia</option>
<option value="Radio-83">Iran</option>
<option value="Radio-84">Iraq</option>
<option value="Radio-85">Ireland</option>
<option value="Radio-86">Israel</option>
<option value="Radio-87">Italy</option>
<option value="Radio-88">Jamaica</option>
<option value="Radio-89">Japan</option>
<option value="Radio-90">Jordan</option>
<option value="Radio-91">Kazakhstan</option>
<option value="Radio-92">Kenya</option>
<option value="Radio-93">Kiribati</option>
<option value="Radio-94">Korea, North</option>
<option value="Radio-95">Korea, South</option>
<option value="Radio-96">Kosovo</option>
<option value="Radio-97">Kuwait</option>
<option value="Radio-98">Kyrgyzstan</option>
<option value="Radio-99">Laos</option>
<option value="Radio-100">Latvia</option>
<option value="Radio-101">Lebanon</option>
<option value="Radio-102">Lesotho</option>
<option value="Radio-103">Liberia</option>
<option value="Radio-104">Libya</option>
<option value="Radio-105">Liechtenstein</option>
<option value="Radio-106">Lithuania</option>
<option value="Radio-107">Luxembourg</option>
<option value="Radio-108">Macau</option>
<option value="Radio-109">Macedonia</option>
<option value="Radio-110">Madagascar</option>
<option value="Radio-111">Malawi</option>
<option value="Radio-112">Malaysia</option>
<option value="Radio-113">Maldives</option>
<option value="Radio-114">Mali</option>
<option value="Radio-115">Malta</option>
<option value="Radio-116">Marshall Islands</option>
<option value="Radio-117">Mauritania</option>
<option value="Radio-118">Mauritius</option>
<option value="Radio-119">Mexico</option>
<option value="Radio-120">Micronesia</option>
<option value="Radio-121">Moldova</option>
<option value="Radio-122">Monaco</option>
<option value="Radio-123">Mongolia</option>
<option value="Radio-124">Montenegro</option>
<option value="Radio-125">Morocco</option>
<option value="Radio-126">Mozambique</option>
<option value="Radio-127">Namibia</option>
<option value="Radio-128">Nauru</option>
<option value="Radio-129">Nepal</option>
<option value="Radio-130">Netherlands</option>
<option value="Radio-131">New Zealand</option>
<option value="Radio-132">Nicaragua</option>
<option value="Radio-133">Niger</option>
<option value="Radio-134">Nigeria</option>
<option value="Radio-135">North Korea</option>
<option value="Radio-136">Norway</option>
<option value="Radio-137">Oman</option>
<option value="Radio-138">Pakistan</option>
<option value="Radio-139">Palau</option>
<option value="Radio-140">Palestinian Territories</option>
<option value="Radio-141">Panama</option>
<option value="Radio-142">Papua New Guinea</option>
<option value="Radio-143">Paraguay</option>
<option value="Radio-144">Peru</option>
<option value="Radio-145">Philippines</option>
<option value="Radio-146">Poland</option>
<option value="Radio-147">Portugal</option>
<option value="Radio-148">Qatar</option>
<option value="Radio-149">Romania</option>
<option value="Radio-150">Russia</option>
<option value="Radio-151">Rwanda</option>
<option value="Radio-152">Saint Kitts and Nevis</option>
<option value="Radio-153">Saint Lucia</option>
<option value="Radio-154">Saint Vincent and the Grenadines</option>
<option value="Radio-155">Samoa</option>
<option value="Radio-156">San Marino</option>
<option value="Radio-157">Sao Tome and Principe</option>
<option value="Radio-158">Saudi Arabia</option>
<option value="Radio-159">Senegal</option>
<option value="Radio-160">Serbia</option>
<option value="Radio-161">Seychelles</option>
<option value="Radio-162">Sierra Leone</option>
<option value="Radio-163">Singapore</option>
<option value="Radio-164">Sint Maarten</option>
<option value="Radio-165">Slovakia</option>
<option value="Radio-166">Slovenia</option>
<option value="Radio-167">Solomon Islands</option>
<option value="Radio-168">Somalia</option>
<option value="Radio-169">South Africa</option>
<option value="Radio-170">South Korea</option>
<option value="Radio-171">South Sudan</option>
<option value="Radio-172">Spain</option>
<option value="Radio-173">Sri Lanka</option>
<option value="Radio-174">Sudan</option>
<option value="Radio-175">Suriname</option>
<option value="Radio-176">Swaziland</option>
<option value="Radio-177">Sweden</option>
<option value="Radio-178">Switzerland</option>
<option value="Radio-179">Syria</option>
<option value="Radio-180">Taiwan</option>
<option value="Radio-181">Tajikistan</option>
<option value="Radio-182">Tanzania</option>
<option value="Radio-183">Thailand</option>
<option value="Radio-184">Timor-Leste</option>
<option value="Radio-185">Togo</option>
<option value="Radio-186">Tonga</option>
<option value="Radio-187">Trinidad and Tobago</option>
<option value="Radio-188">Tunisia</option>
<option value="Radio-189">Turkey</option>
<option value="Radio-190">Turkmenistan</option>
<option value="Radio-191">Tuvalu</option>
<option value="Radio-192">Uganda</option>
<option value="Radio-193">Ukraine</option>
<option value="Radio-194">United Arab Emirates</option>
<option value="Radio-195">United Kingdom</option>
<option value="Radio-196">United States</option>
<option value="Radio-197">Uruguay</option>
<option value="Radio-198">Uzbekistan</option>
<option value="Radio-199">Vanuatu</option>
<option value="Radio-200">Venezuela</option>
<option value="Radio-201">Vietnam</option>
<option value="Radio-202">Yemen</option>
<option value="Radio-203">Zambia</option>
<option value="Radio-204">Zimbabwe</option>
</select>
</div>
<div class="clear"></div>
<div id="q12" class="q full_width">
<a class="item_anchor" name="ItemAnchor12"></a>
<div class="segment_header" style="background:#000080;width:auto;text-align:Left;">
<h1 style="font-size:24px;padding-bottom:20px;padding-top:20px;">Passes</h1>
</div>
</div>
<div class="clear"></div>
<div id="q103" class="q full_width">
<a class="item_anchor" name="ItemAnchor13"></a>
<div class="full_width_space">
<div style="text-align: center;">
<div style="text-align: center;">
<div style="text-align: center;"><strong>Pricing per delegate </strong>(Pricing is subject to 20% tax)</div>
<div style="text-align: center;"> </div>
<div>
<div style="text-align: center;">
<div>Pricing per delegate is based on the date & number of passes you would like. </div>
</div>
<div style="text-align: center;">
<div> </div>
<div> </div>
<div>
<div style="text-align: center;">
<div style="text-align: center;">
<div><span style="color: #008000; font-size: 16px;"><strong><span style="text-decoration: underline;">EARLY BIRD RATE</span></strong></span></div>
</div>
<div style="text-align: center;">
<table style="border-collapse: collapse; width: 417px; border-style: solid; border-color: black; margin-left: auto; margin-right: auto; height: 46px;" border="2" width="313pt" cellspacing="2" cellpadding="2">
<tbody>
<tr style="height: 15.0pt;">
<td class="xl100" style="width: 195.969px; height: 15px;" height="20"><strong>LIVE (In Person)</strong></td>
<td class="xl100" style="width: 208.031px; height: 15px;"><strong>VIRTUAL</strong></td>
</tr>
<tr style="height: 15.0pt;">
<td class="xl100" style="height: 31px; width: 195.969px;" height="20"><strong>£1,750</strong></td>
<td class="xl100" style="width: 208.031px; height: 31px;"><strong>£1,450</strong></td>
</tr>
</tbody>
</table>
<div> </div>
<div> </div>
<div><span style="text-decoration: underline; font-size: 16px;"><strong><span style="color: #ff6600; text-decoration: underline;">FROM 15th September 2023</span></strong></span></div>
<div>
<table style="border-collapse: collapse; width: 417px; border-style: solid; border-color: black; margin-left: auto; margin-right: auto; height: 46px;" border="2" cellspacing="2" cellpadding="2">
<tbody>
<tr style="height: 15.0pt;">
<td class="xl100" style="width: 195.969px; height: 15px;" height="20"><strong>LIVE (In Person)</strong></td>
<td class="xl100" style="width: 208.031px; height: 15px;"><strong>VIRTUAL</strong></td>
</tr>
<tr style="height: 15.0pt;">
<td class="xl100" style="height: 31px; width: 195.969px;" height="20"><strong>£2,150</strong></td>
<td class="xl100" style="width: 208.031px; height: 31px;"><strong>£1,950</strong></td>
</tr>
</tbody>
</table>
</div>
<div> </div>
<div><span style="font-size: 16px; color: #ff0000;"><strong>Bring Colleagues Along and Benefit:</strong></span></div>
<div>
<div> </div>
<div><strong>10% off for 2 Passes</strong></div>
<div><strong>15% off for 3+ Passes</strong></div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="clear"></div>
<div id="q106" class="q required">
<a class="item_anchor" name="ItemAnchor14"></a>
<label class="question top_question" for="RESULT_RadioButton-14">Total number of passes? <b class="icon_required">*</b></label>
<select id="RESULT_RadioButton-14" name="RESULT_RadioButton-14" class="drop_down">
<option></option>
<option value="Radio-0">1</option>
<option value="Radio-1">2</option>
<option value="Radio-2">3</option>
<option value="Radio-3">4</option>
<option value="Radio-4">5</option>
<option value="Radio-5">6</option>
<option value="Radio-6">7</option>
<option value="Radio-7">8</option>
<option value="Radio-8">9</option>
<option value="Radio-9">10</option>
</select>
</div>
<div class="clear"></div>
<div id="q105" class="q full_width">
<a class="item_anchor" name="ItemAnchor15"></a>
<div class="full_width_space">
<div>Please select the number of delegates attending Live &/or Virtually.</div>
</div>
</div>
<div class="clear"></div>
<div id="q107" class="q required">
<a class="item_anchor" name="ItemAnchor16"></a>
<span class="question top_question">LIVE (In person) <b class="icon_required">*</b></span>
<table class="matrix">
<tbody>
<tr class="matrix_row_light">
<td class="question"><label for="RESULT_RadioButton-16-0">Reimbursement and Market Access Conference</label></td>
<td><select name="RESULT_RadioButton-16-0" class="drop_down" id="RESULT_RadioButton-16-0">
<option></option>
<option value="Radio-0">0</option>
<option value="Radio-1">1 Attendee</option>
<option value="Radio-2">2 Attendees</option>
<option value="Radio-3">3 Attendees</option>
<option value="Radio-4">4 Attendees</option>
<option value="Radio-5">5 Attendees</option>
<option value="Radio-6">6 Attendees</option>
<option value="Radio-7">7 Attendees</option>
<option value="Radio-8">8 Attendees</option>
<option value="Radio-9">9 Attendees</option>
<option value="Radio-10">10 Attendees</option>
<option value="Radio-11">Other</option>
</select></td>
</tr>
</tbody>
</table>
</div>
<div class="clear"></div>
<div id="q111" class="q required">
<a class="item_anchor" name="ItemAnchor17"></a>
<span class="question top_question">Virtually <b class="icon_required">*</b></span>
<table class="matrix">
<tbody>
<tr class="matrix_row_light">
<td class="question"><label for="RESULT_RadioButton-17-0">Reimbursement and Market Access Conference</label></td>
<td><select name="RESULT_RadioButton-17-0" class="drop_down" id="RESULT_RadioButton-17-0">
<option></option>
<option value="Radio-0">0</option>
<option value="Radio-1">1 Attendee</option>
<option value="Radio-2">2 Attendees</option>
<option value="Radio-3">3 Attendees</option>
<option value="Radio-4">4 Attendees</option>
<option value="Radio-5">5 Attendees</option>
<option value="Radio-6">6 Attendees</option>
<option value="Radio-7">7 Attendees</option>
<option value="Radio-8">8 Attendees</option>
<option value="Radio-9">9 Attendees</option>
<option value="Radio-10">10 Attendees</option>
<option value="Radio-11">Other</option>
</select></td>
</tr>
</tbody>
</table>
</div>
<div class="clear"></div>
<div id="q108" class="q full_width">
<a class="item_anchor" name="ItemAnchor18"></a>
<div class="full_width_space">
<div>Please note, all registrations will be subjected to our final approval process and a confirmation of your registration will be emailed directly to you once approved. For addtional enquiries, please contact accounts@ttgw.co.uk</div>
</div>
</div>
<div class="clear"></div>
<div id="q72" class="q">
<a class="item_anchor" name="ItemAnchor19"></a>
<span class="question top_question">Add Additional Team Members (Name, Email ID & Job Title) <span class="instructions">🛈</span></span>
<table class="text_list">
<tbody>
<tr class="matrix_row_light">
<td><input type="text" name="RESULT_MatrixTextField-19-0" class="text_field" size="25" maxlength="255" value=""></td>
<td><span class="icon_add"><span class="accessibility_hidden">+</span></span><span class="icon_del"><span class="accessibility_hidden">-</span></span></td>
</tr>
</tbody>
</table>
<input type="hidden" name="MaxAnswers" value="25">
</div>
<div class="clear"></div>
<div id="q18" class="q full_width">
<a class="item_anchor" name="ItemAnchor20"></a>
<div class="segment_header" style="background:#000080;width:auto;text-align:Left;">
<h1 style="font-size:24px;padding-bottom:20px;padding-top:20px;">Payment</h1>
</div>
</div>
<div class="clear"></div>
<div id="q86" class="q required">
<a class="item_anchor" name="ItemAnchor21"></a>
<label class="question top_question" for="RESULT_RadioButton-21">Card Type <b class="icon_required">*</b></label>
<select id="RESULT_RadioButton-21" name="RESULT_RadioButton-21" class="drop_down">
<option></option>
<option value="Radio-0">Amex</option>
<option value="Radio-1">Visa</option>
<option value="Radio-2">Mastercard</option>
<option value="Radio-3">Other</option>
</select>
</div>
<div id="q85" class="q required">
<a class="item_anchor" name="ItemAnchor22"></a>
<label class="question top_question" for="RESULT_TextField-22">Name on Card <b class="icon_required">*</b></label>
<input type="text" name="RESULT_TextField-22" class="text_field" id="RESULT_TextField-22" size="25" value="">
</div>
<div id="q84" class="q required">
<a class="item_anchor" name="ItemAnchor23"></a>
<label class="question top_question" for="RESULT_TextField-23">Card Number <b class="icon_required">*</b></label>
<input type="text" name="RESULT_TextField-23" class="text_field" id="RESULT_TextField-23" size="25" maxlength="19" autocomplete="off" value="">
</div>
<div class="clear"></div>
<div id="q87" class="q required">
<a class="item_anchor" name="ItemAnchor24"></a>
<label class="question top_question" for="RESULT_TextField-24">Expiry <b class="icon_required">*</b></label>
<input type="text" name="RESULT_TextField-24" class="text_field" id="RESULT_TextField-24" size="25" value="">
</div>
<div id="q88" class="q required">
<a class="item_anchor" name="ItemAnchor25"></a>
<label class="question top_question" for="RESULT_TextField-25">CSV <b class="icon_required">*</b></label>
<input type="text" name="RESULT_TextField-25" class="text_field" id="RESULT_TextField-25" size="25" value="">
</div>
<div class="clear"></div>
<div id="q63" class="q required">
<a class="item_anchor" name="ItemAnchor26"></a>
<label class="question top_question" for="RESULT_TextField-26">Billing Address <b class="icon_required">*</b></label>
<input type="text" name="RESULT_TextField-26" class="text_field" id="RESULT_TextField-26" size="54" value="">
</div>
<div class="clear"></div>
<div id="q64" class="q">
<a class="item_anchor" name="ItemAnchor27"></a>
<label class="question top_question" for="RESULT_TextField-27">Address Line 2</label>
<input type="text" name="RESULT_TextField-27" class="text_field" id="RESULT_TextField-27" size="54" value="">
</div>
<div class="clear"></div>
<div id="q65" class="q required">
<a class="item_anchor" name="ItemAnchor28"></a>
<label class="question top_question" for="RESULT_TextField-28">City <b class="icon_required">*</b></label>
<input type="text" name="RESULT_TextField-28" class="text_field" id="RESULT_TextField-28" size="22" value="">
</div>
<div id="q66" class="q required">
<a class="item_anchor" name="ItemAnchor29"></a>
<label class="question top_question" for="RESULT_TextField-29">State/Province/Region <b class="icon_required">*</b></label>
<input type="text" name="RESULT_TextField-29" class="text_field" id="RESULT_TextField-29" size="24" value="">
</div>
<div class="clear"></div>
<div id="q67" class="q required">
<a class="item_anchor" name="ItemAnchor30"></a>
<label class="question top_question" for="RESULT_TextField-30">Zip/Postal Code <b class="icon_required">*</b></label>
<input type="text" name="RESULT_TextField-30" class="text_field" id="RESULT_TextField-30" size="22" value="">
</div>
<div class="clear"></div>
<div id="q69" class="q required">
<a class="item_anchor" name="ItemAnchor31"></a>
<label class="question top_question" for="RESULT_TextField-31">Country <b class="icon_required">*</b></label>
<input type="text" name="RESULT_TextField-31" class="text_field" id="RESULT_TextField-31" size="54" value="">
</div>
<div class="clear"></div>
<div id="q74" class="q full_width">
<a class="item_anchor" name="ItemAnchor32"></a>
<div class="segment_header"
style="width:auto;text-align:Left;background-repeat:repeat;background-color:transparent;background-image:url("/images/stock/2015/BusinessAndTechnology/Business03.jpg");background-size: cover;background-position: 50% 50%;">
<h1 style="font-size:24px;padding-bottom:20px;padding-top:20px;">Confirmation</h1>
</div>
</div>
<div class="clear"></div>
<div id="q44" class="q full_width">
<a class="item_anchor" name="ItemAnchor33"></a>
<div class="full_width_space" style="text-align:center"><a href="https://www.ttgroupworldwide.com/terms-and-conditions/" class="link" target="_blank">Terms & Conditions</a></div>
</div>
<div class="clear"></div>
<div id="q78" class="q required">
<a class="item_anchor" name="ItemAnchor34"></a>
<label class="question top_question" for="RESULT_RadioButton-34">Registration will require payment in full, after which, if you cancel, you may exchange for a credit note. <b class="icon_required">*</b></label>
<select id="RESULT_RadioButton-34" name="RESULT_RadioButton-34" class="drop_down">
<option></option>
<option value="Radio-0">I Agree</option>
</select>
</div>
<div class="clear"></div>
<div id="q113" class="q required">
<a class="item_anchor" name="ItemAnchor35"></a>
<label class="question top_question" for="RESULT_RadioButton-35">Do you agree to our Terms & Conditions <b class="icon_required">*</b></label>
<select id="RESULT_RadioButton-35" name="RESULT_RadioButton-35" class="drop_down">
<option></option>
<option value="Radio-0">Yes</option>
</select>
</div>
<div class="clear"></div>
<div id="q76" class="q required">
<a class="item_anchor" name="ItemAnchor36"></a>
<span class="question top_question">Signature <b class="icon_required">*</b></span>
<input type="hidden" name="RESULT_TextField-36_30" id="RESULT_TextField-36_30" value="">
<input type="hidden" name="RESULT_TextField-36_SVG" id="RESULT_TextField-36_SVG" value="">
<div class="signature text_field">
<div>
<div style="padding:0 !important;margin:0 !important;width: 100% !important; height: 0 !important;margin-top:-1em !important;margin-bottom:1em !important;"></div><canvas class="jSignature" width="550"
style="margin: 0px; padding: 0px; border: none; height: 138px; width: 100%;" height="138"></canvas>
<div style="padding:0 !important;margin:0 !important;width: 100% !important; height: 0 !important;margin-top:-1.5em !important;margin-bottom:1.5em !important;"></div>
</div>
</div>
<div class="signature_clear"><span>clear</span></div>
</div>
<div class="clear"></div>
</div>
<!-- END_ITEMS -->
<script>
var itemInstructions = {
72: "Please include - Name, Email Address & Job Title"
};
</script>
<div class="outside_container">
<div class="buttons_reverse"><input type="submit" name="Submit" value="Submit" class="submit_button" id="FSsubmit"></div>
</div>
</form>Text Content
subject_line 2ND ANNUAL EUROPEAN MEDICAL DEVICE AND DIAGNOSTIC REIMBURSEMENT AND MARKET ACCESS CONFERENCE | 25TH-26TH OCTOBER 2023 | STEIGENBERGER AIRPORT HOTEL BERLIN, GERMANY ATTENDEE DETAILS First Name * Last Name * Email Address * Confirm Email Address * Mobile Number * Job Title * Booking Contact * Rachel D. COMPANY DETAILS Name Of Organization * City * Country * Afghanistan Albania Algeria Andorra Angola Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas, The Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burma Burundi Cambodia Cameroon Canada Cabo Verde Central African Republic Chad Chile China Colombia Comoros Congo, Democratic Republic of the Congo, Republic of the Costa Rica Cote d'Ivoire Croatia Cuba Curacao Cyprus Czechia Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France Gabon Gambia, The Georgia Germany Ghana Greece Grenada Guatemala Guinea Guinea-Bissau Guyana Haiti Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, North Korea, South Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Montenegro Morocco Mozambique Namibia Nauru Nepal Netherlands New Zealand Nicaragua Niger Nigeria North Korea Norway Oman Pakistan Palau Palestinian Territories Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Qatar Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten Slovakia Slovenia Solomon Islands Somalia South Africa South Korea South Sudan Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Venezuela Vietnam Yemen Zambia Zimbabwe PASSES Pricing per delegate (Pricing is subject to 20% tax) Pricing per delegate is based on the date & number of passes you would like. EARLY BIRD RATE LIVE (In Person) VIRTUAL £1,750 £1,450 FROM 15th September 2023 LIVE (In Person) VIRTUAL £2,150 £1,950 Bring Colleagues Along and Benefit: 10% off for 2 Passes 15% off for 3+ Passes Total number of passes? * 1 2 3 4 5 6 7 8 9 10 Please select the number of delegates attending Live &/or Virtually. LIVE (In person) * Reimbursement and Market Access Conference 01 Attendee2 Attendees3 Attendees4 Attendees5 Attendees6 Attendees7 Attendees8 Attendees9 Attendees10 AttendeesOther Virtually * Reimbursement and Market Access Conference 01 Attendee2 Attendees3 Attendees4 Attendees5 Attendees6 Attendees7 Attendees8 Attendees9 Attendees10 AttendeesOther Please note, all registrations will be subjected to our final approval process and a confirmation of your registration will be emailed directly to you once approved. For addtional enquiries, please contact accounts@ttgw.co.uk Add Additional Team Members (Name, Email ID & Job Title) 🛈 +- PAYMENT Card Type * Amex Visa Mastercard Other Name on Card * Card Number * Expiry * CSV * Billing Address * Address Line 2 City * State/Province/Region * Zip/Postal Code * Country * CONFIRMATION Terms & Conditions Registration will require payment in full, after which, if you cancel, you may exchange for a credit note. * I Agree Do you agree to our Terms & Conditions * Yes Signature * clear