Registration form e/MTIC course Clinical Regulatory 2023 Required fields are marked with an asterisk (*) Courseregistration (e/MTIC related only) 1/2-day course* [14-17 hrs] Date: Thursday, September 14, 2023 Personal data Surname (family name)* Insertion ('van' or 'van der') Firstname* Initials* Title Gender* M F Telephone number (preferably mobile in case of last minute changes in program)* Contact data E-mail* Name hospital/company/institution* Street and number hospital/company/institution* Postalcode and + city of hospital/company/institution* Position* Department* I am in training as e/MTIC Cardiovascular e/MTIC Neuro e/MTIC Oncology e/MTIC Perinatal e/MTIC Sleep e/MTIC Other or else e/MTIC other Else If e/MTIC other or else, please write down your field of training Billing In case of a no show, we will bill you € 50. Send the bill to* Homeaddress Hospital/company/institution TU/e (I am a CI/QME/PhD trainee/eMTIC)* Costcenter and Activity number obligatory Costcenter/Projectnumber/Activitynumer/Ordernumber/reference number (with homeaddress-not applicable) TU/e trainees: please also fill in your Costcenter and project or activitynumbers. Thank You!* Course expectations What do I expect from this course (day)?* Attention: After 'submit', click on 'verzenden/send'. If you have not received a confirmation of registration by email please check your SPAM folder and notify firstname.lastname@example.org directly. Thank you! Don't fill this field!