Registration Form
Personal information
*
Name
Surname
Fiscal code
*
If not applicable, please digit 000
Affiliation
*
Entity, Hospital, University
Contractual Form
*
Please Select
Employee
Freelance
Affiliated with SSN
Affiliated with Other
Disoccupied
Student/Resident
Please select an option
Field
*
Please Select
Anato-Pathology
Audiology
Maxillo-facial surgery
Plastic and reconstructive surgery
Otolaryngology
Medical Oncology
Radiation Oncology
Radiologist
Please select an option
Contact information
*
E-mail address
Phone number
Please indicate if you have been recruited by a commercial company operating in the healthcare sector:
*
Please Select
Yes
No
A healthcare professional is considered to be recruited if he/she benefits from direct and indirect economic and non-economic advantages from commercial companies operating in the healthcare field for participation in training events,
Please indicate the company
Registration Fees
*
prev
next
( X )
Single participation
€100.00
€
100.00
Multiple participations from the same MTB
€50.00
€
50.00
Multidisciplinary Tumor Board
If you chose "Multiple participations from the same MTB" please indicate the name of affiliation of the MTB
Select the payment method:
*
Bank transfer (the secretariat will send the details via e-mail)
Online credit card (the secretariat will send a personal link via e-mail)
Invoicing information
*
Header of the invoice
Fiscal address: street, town, postal code
Date and place of birth
VAT number (if applicable)
Any notes
Send
Should be Empty: