MLCTO 2021 - Request for grant support - July 1st, 2nd and 3rd - Nice

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 ?*

Coronary angioplasty
Peripheral angioplasty
Structural heart interventions
Rhythmology
Interventional radiology
Endovascular procedures
Interventional radiology
Vascular surgery
Cardiac surgery

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

Do you have a CTO PCI program in your cath lab?*

Yes
No

How many CTO PCI have been performed during 2020 in your center?*

How many CTO PCI did you personally perform during 2020 ?*

How many CTO PCI do you consider performing this year?*

Did you participate to one of the previous ML CTO Editions?*

Yes
No

How have you heard about the ML CTO Course?*

Newsletter
Website (browser)
Brochure
Industry
Peer

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?*

PACKAGES

Physician : select your package*

3 days package
2 days package

Thank you for selecting the package you wish

Paramedic : select your package*

2 days package

Thank you for selecting the package you wish

Fellow : select your package*

3 days package
2 days package

Thank you for selecting the package which you wish

ACCOMMODATION

Physician : select the night(s) according to your 3 days package*

Night of June, 30th (June 30th to July 1st, day before the congress)
Night of July 1st (July 1st to July 2nd)
Night of July 2nd (July 2nd to 3rd)
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.

Fellow : select the night(s) according to your 3 days package*

Night of June, 30th (June 30th to July 1st, day before the congress)
Night of July 1st (July 1st to 2nd)
Night of July 2nd (July 2nd to 3rd)
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.

Physician : select the night(s) according to your 2 days package*

Night of June, 30th (June 30th to July 1st, day before the congress)
Night of July 1st (July 1st to 2nd)
Night of July 2nd (July 2nd to 3rd)
I don't need accommodation

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

Fellow : select the night(s) according to your 2 days package*

Night of June, 30th (June 30th to July 1st, day before the congress)
Night of July 1st (July 1st to 2nd)
Night of July 2nd (July 2nd to 3rd)
I don't need accommodation

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

Paramedics : select the night(s) according to your 2 days package*

Night of June, 23h (24th to 24th, day before the congress)
Night of July 1st (July 1st to 2nd)
Night of July 2nd (July 2nd to 3rd)
I don't need accommodation

Please select a maximum of 2 nights This package 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.

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

MLCTO DINNER (Thursday, July 1st)*

Yes, I take part to the gala dinner
I will be accompanied by one person (70€)
No, I do not take part to the gala dinner

Email

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

MLCTO 2021 – Request for grant support – July 1st, 2nd and 3rd – Nice