AGENCE NATIONALE DE SECURITE DU MEDICAMENT REPUBLIQUE FRANCAISE ET DES PRODUITS DE SANTE – ANSM
Request for travel tickets Request for accommodation
(Payment of the service provider directly by ANSM)
Date of the request:APPLICANT
First and last name Phone number
Email address for sending tickets or vouchers
RECIPIENT PRIM – e-mail : [email protected] Fax : 01.55.87.31.24
OBJECT Title of the meeting Date of the meeting TRAVEL INFORMATION:
Date of birth (for e-ticket ; format dd/mm/yyyy)
Number of the card Period of validity
Start date End date Transport loyalty card (if applicable)
Title :
Identity card or passport for flights Date(s) of
travel
Mode of
transport From To Desired schedule
Departure Arrival
ACCOMODATION: Support within the limit of 120€ per night (breakfast included), near the place of the meeting preferably to avoid additional transport costs.
TO BE FILLED ONLY IF REQUEST FOR A HOTEL RESERVATION BY ANSM
Reference of the desired hotel or the place near which it
must be located (ANSM, station, …) Number of nights Date of arrival Date of departure
Eventual comments:
ANSM : 143-147, Boulevard Anatole France - 93285 SAINT-DENIS - Tél . : 01.55.87.30.00
