MLCTO 2022 - Request for grant support - June 30th, July 1st and 2nd - Nice - 2022

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 2021 in your center?*

How many CTO PCI did you personally perform during 2021 ?*

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

Are you vaccinated ?*

Yes
No
In progress

In order to respect the healthcare protocol and the safety of all, we would like to give access to the ML CTO to vaccinated physicians as a priority.

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

Yes
No

Please indicate the edition(s)*

ML CTO 2018
ML CTO 2019
ML CTO 2020 (edition 100% virtual)
ML CTO 2021 (hybrid edition)

How have you heard about the ML CTO Course?*

Newsletter
Website (browser)
Social media
Industry
Peer
Other

Please indicate which industry and country ?

Other (please specify)*

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

ACCOMMODATION

Select the number of night(s) you would like to stay*

Night of June, 29th (June 29th to June 30th, day before the congress)
Night of June 30th ( June 30th to July 1st)
Night of July 1st (July 1st to 2nd)
I don't need accommodation

This package includes a single room for two or 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*

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

ML CTO DINNER (Thursday, June 30th)*

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

Name

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

MLCTO 2022 – Request for grant support – June 30th, July 1st and 2nd – Nice – 2022