Application for passive participation

 

Except the application form you have to send us a scan of your bank transfer. E-mail it to treasurer@icmsbg.org. For further details see registration.

Note

Information marked with a * is required!
You can click the grey terms in case you are not sure which information to give.
Please read our application guidelines and abstract guidelines before filling in the form below.

Personal Information

Your Title* (Dr., Mrs., Mr., ...) :
Your First Name (+ Optional Middlename)*:
Your Last Name*:
Your Date of Birth*: (Year/Month/Day, e.g. 71/12/28 or 1971/12/28)
Your Passport Number*:
Your Passport Country*:
Date of Expiry*:
Your E-mail Address*:
Your Mobile Phone Number:
Your Fax Number:
Your Post Address*:
Your Post Address (continue):
Country*:
If Other:


University

Your University*:
Your Department:

Subject of Your Curriculum:

Medicine
Dentistry
Pharmacy
Other (Please Specify):   
Do you want a post congress tour? Yes       No
Do you want us to arrange your accomodation? Yes       No


 

 
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