ECC 2024 - Grant support request

Family name*

First name*

E-mail address*

Cell phone number*

Cell phone number (only) Please indicate in front of your phone number, the country dialling code of your country.

Position*

Affiliated Medical Center*

City*

Country*

REGISTRATION

I register as :*

Physician
Fellow

N° RPPS (only for french physician)*

If you do not have an RPPS number, please note in this section "N/A".

What do you perform the most ?*

Structural
Coronary
Both

Did you ever face a complication during an endovascular cardiac procedure?*

Yes
No

Did you manage it on your own?*

Yes
No

Have you already attended this course?*

Yes
No

Did you present a complication case?*

Yes
No

What do you expect to learn/improve during this course?*

How have you heard about ECC ?*

Newsletter
Website (browser)
Brochure
Industry
Peer
Partners (scientific society - media - events)
Other

Please indicate which industry and country ?

Please indicate the name of your colleague ?

Other (please specify)

What are the reasons why you want to attend this Course?*

ACCOMMODATION

Select the night(s) according to your wishes*

Night of June 5th (5th to 6th)
Night of June 6th (6th to 7th)
I don't need accommodation

This package includes a single room for 2 nights at the hotel. All the information concerning your hotel will passed on to you before the event.

Special accommodation requests

TRANSPORT

Airport and/or station tranfers will be handled by the organization. You will receive detailed information in your travel book few days before your departure by email.

Your flight will be in economic class, if you wish to travel in business class, it will be to your own charge.

Do you need a transportation booking?*

Yes
No

Departure city*

Departure date*

Departure time*

Morning
Afternoon
Evening

Return city (if it is not departure city)

Return date*

Return time*

Morning
Afternoon
Evening

Membership card type and number (airline, railroad company...)

Preferred Airline company

Upload your passport or ID Card*

Types de fichiers acceptés : jpeg, jpg, png, pdf, gif, Taille max. des fichiers : 128 MB.

Essential to book your travel. Thanks.

Special travel requests (aisle, window...)

Thank you for sending your receipts and your bank details after the congress to :
organization@ecc-congress.com

We will reimburse you up to 500€ by bank transfer within 4 weeks after the conference . If you use your personal vehicle, the allowances of refund will be calculated on a standard kilometers referral.

Phone

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