Registration forms MUST be completed electronically, otherwise they will not be accepted. Please, type in block letters and press the "SEND" button. In the next page, you will be redirected to our Bank for Credit Card Submission. In case you experience some problems during the registration process, please email to ebagnoli@dgmp.it

D.G.M.P. s.r.l. Via A. Gozzini, 4 56121 PISA (ITALY)  Tel: + 39 050 989.310 Fax: + 39 050 981.264 E-mail: info@dgmp.it

ATTENDEE DATA

PERSONAL DATA
Name:		Surname:
Date of Birth: (dd/mm/yyyy)		Place of Birth:
Home Address
Zip code:		City:
State:		Country:
Phone:		Fax:
Mobile Phone:		E-mail:
INSTITUTE DATA
Inst, Hosp, Div:		Address:
Zip code:		City:
State:		Country:
Phone:		Fax:
E-mail:
Med. Specialization

 

REQUIRED MATERIALS

• Curriculum vitae with all relevant information related to personal studies, research, scientific publications and
  professional experience
• Degree certificate and post-graduate specializations certificates in jpeg format
• Accident Insurance with a validity abroad
• Third Party Insurance with a validity abroad
• A copy of Identity Card or Passport

REGISTRATION FEE

 

Pratical and Basic Theoretical Program + Complimentary Advanced Theoretical Program

I wish to attend the 5 day Complimentary Program € 1.500,00 (VAT included)
I wish to attend the 10 day Complimentary Program € 2.500,00 (VAT included)
I wish to attend a Complimentary Long Period Program (to be quoted upon demand)

I will be available to attend the program in the following weeks:

1st choice from (dd/mm/yyyy)		to (dd/mm/yyyy)
2nd choice from (dd/mm/yyyy)		to (dd/mm/yyyy)
3rd choice from (dd/mm/yyyy)		to (dd/mm/yyyy)

The Organizing Secretariat will confirm one of the proposed periods.

NOTES

Remaining Chars

 

PAYMENT

As payment of the above mentioned fees for the total amount of :  Euro

 

 

PAYMENT BY BANK TRANSFER: Bank: BANCA POPOLARE DI VICENZA – AGENZIA 850 BRESCIA 7 VIA S. BARTOLOMEO N. 17 – 25128  BRESCIA IBAN: IT03 H057 2811 2418 5057 0793 863 SWIFT CODE: B P V I I T 2 2 X X X Please note that the bank transfer must be free of charge for recipient. A copy of the bank transfer must be sent by fax to +39 050 981264 along with the registration form.