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SMPE/e
Inschrijvingsformulier SMPE/e cursus 'Elektrische Veiligheid 10 juni 2024'
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Cursussen voor Technologen in de zorg
Elektrische Veiligheid
Inschrijvingsformulier SMPE/e cursus 'Elektrische Veiligheid 10 juni 2024'
Required fields are marked with an asterisk (*)
Persoons gegevens
Achternaam
*
Tussenvoegsel (van, van der)
Voornaam
*
Initialen
*
Titel
Geslacht
*
M
V
Geboortedatum (i.v.m. certifcaat): svp uitschrijven bijv. 1 juli 1994
*
Geboorteplaats (i.v.m. certifcaat)
*
Telefoon (bij voorkeur gsm i.v.m. eventuele last minute wijzigingen in programma)
*
Ik wil mij inschrijven voor:*
Elektrische Veiligheid 10 juni 2024
Dieetwensen
Contact gegevens
E-mail
*
Straat + huisnummer huisadres
*
Postcode en woonplaats huisadres
*
Naam ziekenhuis/instelling/overig
*
Straat en huisnummer (geen postbus!) ziekenhuis/instelling/overig
*
Postcode en plaats ziekenhuis of instelling
*
Functie
*
Afdeling
*
Ik ben in opleiding als
Klifio
QME i.o.
CI i.o.
AIO
HSD
Anders
Indien anders, te weten als
Ik volg deze cursus in het kader van nascholing als
Klinisch Fysicus
Arts
Anders
Facturering
Factuur sturen naar
*
Huisadres
Ziekenhuis/instelling/overig
TU/e (ik ben een CI/QME-trainee)
Kostenplaats-/referentie-/project-/ordernummer (bij huisadres: NVT)
*
Cursusverwachtingen
Wat verwacht ik van deze cursus?
*
Let op: Na 'verzenden', druk op 'volgende'. Indien u geen bevestiging heeft ontvangen: check uw SPAM folder. Mailt u anders direct naar smpee@tue.nl. Dank u!
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