EDUCATIONAL GRANT - SUBMISSION FORM

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Personal Information

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Last name*

First name*

Mobile phone

E-mail

Date of birth*

City of birth*

CF/SSN
If you are not an Italian resident,
please flag SSN

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SSN

Residence Information

Address*

City*

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Country*

Provincia Only for Italy

Professional Information

Profession*

Specialty*

Hospital/Company/University

Department

Educational Grant

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€1,000.00 – HCP Registration Only

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€3,000.00 – HCP Full Package

Terms and conditions of participation

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I confirm and accept the terms and conditions

Processing of personal data

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I declare that I have read and accepted the Information on the processing of personal data