PACKAGE FRANCE – Logistics arrangements – MLSF 2019 – NICE PACKAGE FRANCE – Logistics arrangements – MLSF 2019 – NICE https://form.comnco.net/wp-content/uploads/2018/10/Capture-d’écran-2018-10-02-à-15.51.59.png 438 366 Com&Guest Com&Guest https://form.comnco.net/wp-content/uploads/2018/10/Capture-d’écran-2018-10-02-à-15.51.59.png 2 octobre 2018 2 octobre 2018 PACKAGE FRANCE - Logistics arrangements - MLSF 2019 Thanks for answering within 15 days * field mandatory Family name*First name*E-mail adress*Cell phone number*Country*City*Affiliated Medical Center*N° RPPS (Répertoire Partagé des Professionnels de Santé)*This number is only for french physician.RegistrationI register as :* Physician Fellow Could you please precise your speciality :* Interventional cardiologist Cardiac surgeon Other Other (please indicate your speciality) :*How many percutaneous interventions are performed in your center per year ?*How many structural heart diseases interventions are performed in your center per year ?*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 interventions in structural heart diseases do you personally practice per year ?*How many TAVI/TMVR do you perform per year?*How have you heard about the MLSF workshop?*NewsletterWebsite (browser)BrochureIndustryPeerOtherPlease indicate the name of your colleague?*Please indicate which industry*Other (please specify)*What are the reasons why you want to attend this Conference ?*AccommodationHOLIDAY INN - Port Saint Laurent 67 Promenade Des Flots Bleus, St. Laurent Du Var, 06700 NiceSelect the night(s) according to your package* Night of April 3rd (3rd to 4th, day before the congress) Night of April 4th (4th to 5th) I don't need a accommodation Single room, breakfast included. The extra and added night will be charged to you (and has to be paid directly to the Hotel). If you need a double room (charged to you), please keep us informed in the part below. If you will be accompanied by one person (15€).Special accommodation requestsTransportAirport 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?*YesNoDeparture city*Departure date*Select your time slot for your departure*On morningOn afternoomOn eveningReturn city (if it is not departure city)Return date*Select your time slot for your return*On morningOn afternoomOn eveningMembership card type and number (airline, railroad company...)Preferred Airline companyDownload your passport or ID Card*Types de fichiers acceptés : jpeg, jpg, png, pdf, gif.Essential to book your travel. Thanks.Special travel requests (aisle, window...)If you decide to make your own travel arrangements, thank you for sending your receipts and your mailing address or your bank details after the congress to : Com & Co 15 Bd Grawitz 13016 MarseilleOr by email to : email@example.comWe will proceed to your refund by check or by bank transfer within 4 weeks, on a 500€ basis for France. If you use your personal vehicle, the allowances of refund will be calculated on a " Mappy " basis.SOCIAL PROGRAMSOCIAL DINNER (Thursday 4th) Yes, I take part to the gala dinner I will be accompanied by one person (50€) No, I do not take part to the gala dinner Special requestsPersonal data* By sending this form, I agree that my personal data might be used for the purposes of my logistic arrangements by the company or any service providers that may need it. NameCe champ n’est utilisé qu’à des fins de validation et devrait rester inchangé.