EASIM 2019 Application

An application link for the 2nd European Advanced School of Internal Medicine (EASIM) in Riga

Course dates: 23 – 25 November 2019 (Saturday to Monday)

Venue: Radisson Hotel Old Town Riga, Riga, Latvia

Target audience: up to 15-20 young Internal Medicine (IM) specialists from European countries in the first few years after completion of postgraduate training in IM.

Course fee package: 500 Euros (Early Bird; 550 Euros regular) per person which will include the following - course costs, accommodation in Radisson Hotel Old Town Riga for 3 nights (November 23-25, 2019), all meals, school facilities etc.

Webpage: http://easim2019.mozello.lv/
Please, complete and submit the application link for EASIM 2019 by Monday, 12th August 2019 (Early Bird) or by Tuesday, 24th September 2019.

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* 1. NAME OF AN APPLICANT:

FAMILY NAME:

FIRST NAME:

MIDDLE NAME (if any):

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* 2. POSTAL ADDRESS AND COUNTRY:

Postal address:

Postal address (2nd line):

COUNTRY:

Postal address and contact details of a payer (if different for invoice; state N/A if the same):

Postal address of a payer (2nd line) - state N/A if the same:

Do you need a visa invitation (Yes/No):

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* 3. Date of Birth:

Date:

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* 4. Gender (M/F):

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* 5. E-mail:

E-mail 1:

E-mail 2 (alternative) - optional, state N/A if the same:

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* 6. Mobile phone (including country code +XX-xxxx...):

Mobile phone:

Alternative phone - optional, state N/A if the same: