Registration - Myeloma Workshop 2019

Please fill in the required fields marked by *.

Physicians Education

Yes, I will attend on Friday, April 5th, 2019 Yes, I will attend on Saturday, April 6th, 2019

Personal Information

Mandatory field Salutation:*

Title:

Mandatory field First name:*

Mandatory field Last name:*

Clinic/Institute:

Street/PO Box:

Zipcode/Town:

Country:

Phone:

Mandatory field Email:*

Participation Attestation - to be forwarded to the Regional Medical Chambers

Upon entering your EFN Number, and provided your attendance on the day of the event, we will automatically report your attendance to the state medical chamber. Please ensure you sign the attendance sheet daily.

EFN (if exists):

Confirmation of participation

Yes, in addition to reporting my attendance to the regional medical chamber, I additionally need a “Certificate of Attendance” No, I do not need an additional confirmation of participation

Complete registration

Notes:

I am aware of the privacy policy. I hereby provide my consent to store above provided information to process my participation at the myeloma workshop.