ELEC 2021 - Request for a grant support - March 11th to 13th, Dijon

Family name*

First name*

E-mail adress*

Cell phone number*

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

Affiliated Medical Center*

Country*

City*

REGISTRATION

I register as :*

Physician
Fellow
Paramedics

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 in your daily practice ?*

Interventional oncology
Interventional radiology : Diagnostic
Interventional radiology : Embolizations procecures
Interventional radiology : Visceral and Peripheral angioplasties
Interventional radiology : Venous interventions

How many embolizations are performed per year in your center?*

How many embolizations did you perform in 2020?*

How many liquid embolizations did you personally perform during 2020?*

How many liquid embolizations do you consider to perform this year?*

How have you heard about ELEC ?*

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 March, 11th (11th to 12th)
Night of March, 12th (12th to 13th)
I don't need accommodation

This package includes a single room for three 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*

Essential to book your travel. Thanks.

Special travel requests (aisle, window...)

SOCIAL PROGRAM

ELEC Dinner*

Yes, I take part to the gala dinner
I will be accompanied by one person (60€)
No, I do not take part to the gala dinner

Name

Ce champ n’est utilisé qu’à des fins de validation et devrait rester inchangé.

ELEC 2021 – Request for a grant support – March 11th to 13th, Dijon