Participant Information

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* 1. ESCMID Membership Number

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* 2. Title

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* 3. First name

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* 4. Last name

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* 5. Institute/Company

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* 6. Department

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* 7. Address line 1

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* 8. Address line 2

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* 9. City

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* 10. ZIP/Postal code

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* 11. Country

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* 12. Email address

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* 13. Phone number

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* 14. Nationality

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* 15. Date of birth (DD/MM/YYYY)

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

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

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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 eucic@escmid.org

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