Workshop Registration - joimax international

Please understand that we have preliminary criteria which have to be accomplished for participants. For every course a specific agenda will be prepared providing all details related to the selected date, e.g. location, time schedule, hotel options, faculties. In general, international courses are held in English.

WORKSHOP CATEGORY *

Date *

PARTICIPANT*

Ms.Mr.Dr.

FIRST NAME, LAST NAME, MEDICAL DESIGNATION (MD, PhD, DO, etc.)*

SPECIALIZATION*

ENDOSCOPIC EXPERIENCE*

YesNo

DEPARTMENT / FUNCTION

INSTITUTION / PRIVATE PRACTICE*

STREET ADDRESS OF INSTITUTION / PRIVATE PRACTICE*

CITY, STATE, ZIP CODE OF INSTITUTION / PRIVATE PRACTICE*

WHAT YEAR OF YOUR RESIDENCY/FELLOWSHIP ARE YOU IN? *

WHAT ARE YOUR PLANS AFTER YOUR RESIDENCY/FELLOWSHIP? *

COUNTRY*

PLEASE, LEAVE YOUR EMAIL AND PHONE NUMBER*

I accept the privacy policy*

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