III INTERNATIONAL EPIRARE WORKSHOP - Rare disease and orphan drug registries

Application form

Register online to the III INTERNATIONAL EPIRARE WORKSHOP - Rare disease and orphan drug registries, Istituto Superiore di Sanità - Rome (Italy), November 24-25, 2014.

Participation to the Workshop is free.

Question Title

* 1. PERSONAL DETAILS

Family name: *

First name: *

Date of birth (dd/mm/yy): *

Place of birth: *

Town:

ZIP Code:

Country:

E-mail: *

Phone number:

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* 2. Gender:

Male

Female

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* 3. PROFESSIONAL DATA

Qualification:

Company name:

Address:

Town:

ZIP Code:

Country:

Fax:

Phone number:

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* 4. POSITION

Company activity (Public health organization, University,etc.):

Charge:

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* 5. Permanent position:

Yes

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* 6. Privacy policy agreement:

Information collected on this form will be held in accordance to the d.lgs. 196/2003 for the purposes of processing your application and for student administration. It will be held securely and not passed on to third parties. according to the art. 13 of the above mentioned law, you have the right to ask for the amendment or cancellation of your data.
I.S.S - Istituto Superiore di Sanità is responsible for the data handling and processing.

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