Registration Form

(For online registration)
Deadline: October 30,2006

Theme Strategies to improve results in Cardio-vascular  & Thoracic surgery
1. Please take note that the registered name will be printed on Badge.
2. Please print or type clearly.
3. Use separate form for each registrant.
Please tick the appropriate box: Professor Dr. Mr. Ms.
Family Name/ last name:
First Name:
Middle Name:
Hospital / Organization:
Mailing Address:
City:
Country:
Zip/ Postal Code:
Address is: Home Office
Day Time Telephone:
(Country Code /City Code/ Number)
Fax:
Email:
Cell/ Mobile Phone:

Please Check Where Applicable:
 Full delegate (physician)
Trainee , Student
Paramedic/nurse/technologist
Exhibitor
Accompanying person
Name of the registered person that you are accompanying:

Mode of Payment:

Cheque Cash Credit Card
 
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