ML CTO ENDOVASCULAR 2024 - Request for grant support

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
Paramedic

ID medical registration number*

DAYS OF PARTICIPATION

I wish to participate for :*

3 days
2 days

I select the desired days

May, Thursday 2nd and Friday 3rd
May, Friday 3rd and Saturday 4th

EVALUATION

What do you perform in your daily practice ?*

Peripheral angioplasties
Vascular and aortic procedures
Venous interventions
Interventional radiology
Vascular surgery
Interventional cardiology

What are your main CTO interventions?*

How many endovascular interventions are performed per year in your center?*

How many endovascular CTO have been treated during 2023 in your center?*

How many endovascular CTO did you personally treat during 2023?*

How many endovascular CTO do you consider to treat this year?*

How have you heard about the ML CTO Course?*

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

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

What do you want?

I would like to have an accommodation
I don't need an accommodation

Select the night(s) according to your 3 days registration*

Night of May, 1st (1st to 2nd, day before the congress)
Night of May, 2nd (2nd to 3rd)
Night of May, 3rd (3rd to 4th)
I don't need accommodation

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

Select the night(s) according to your 2 days registration*

Night of May, 1st (1st to 2nd, day before the congress)
Night of May, 2nd (2nd to 3rd)

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

Select the night(s) according to your 2 days registration*

Night of May, 2nd (2nd to 3rd)
Night of May, 3rd (3rd to 4th)

This registration includes a single room for two 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.
Change fees for rescheduling flights or train without justification (health or work related reasons) will be at your charge.
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...)

SOCIAL PROGRAM

MLCTO Endovascular 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

Included on the registration fees

Name

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