Cologne, Germany -4 - 8 November, 2019 - Registration form for local module for the EUCIC Infection Prevention and Control Certificate

Question Title

* 1. Personal information about the trainee

ESCMID membership number

Title

First name

Last name

Institute/Company

Department

Address line 1

Address line 2

City

ZIP/Postal code

Country

Email address

Phone number

Nationality

Date of Birth

Gender

Question Title

* 2. Last obtained (relevant) degree (e.g. MSc, BSc, PhD, MD)

Please upload a copy of your diploma

PDF, DOCX, DOC file types only.

Choose File

No file chosen

Question Title

* 3. Are you already a specialist in CM, ID, IC/HH or Public health

Please upload documentation

PDF, DOCX, DOC file types only.

Choose File

No file chosen

Please note that your registration will only be completed once you have paid the required amount.

Upon pressing the submit button, your registration form will be evaluated for its completeness and we will send you the bank details for payment. After receipt of the registration fee, you will receive a confirmation of payment and registration.

In case you experience any difficulties with this form please contact william.cady@escmid.org