TRAVEL GRANTS- March 16th -18th Abu Dhabi, U.A.E SEUD 2023

Family name*

First name*

E-mail address*

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*

EVALUATION

Have you submitted an abstract into our platform?*

Yes
No

TITLE OF THE ABSTRACT*

What is your professional activity/position?*

Physician/Resident
Physician/Attending
Physician/Chief of department
Biologist
Nurse

Where do you hold your primary professional activity?*

Private non-teaching institution
Private teaching institution
Public non-teaching institution
Private teaching institution
Other

Primary professional activity center*

Which is your main field of interest?*

How would you define yourself?*

Clinician
Surgeon
Imaging expert
Fertility doctor/biologist
Basic researcher
Epidemiologist
Pain expert

ACCOMMODATION

- 2 nights included for Middle East and North African countries
- 3 nights included for Europeans and Out of Europe countries

What do you want?

I would like to have an accommodation

I don't need an accommodation

Select the night(s)
Night of March, 15th (15th to 16th, day before the congress)
Night of March, 16th (16th to 17th)
Night of March, 17th (17th to 18th)
Single room use, Breakfast included. All the information concerning your hotel will be given before the event.

Special accommodation requests

TRANSPORT

Maximum budget will be set as followed:
- Middle East and North Africa: 600€
- Europe : 800€
- Out of Europe: 1000€

Your flight will be in economic class, if you wish to travel in business class, it will be to your own charge.

You will receive detailed information in your travel book few days before your departure by email.

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)*
Types de fichiers acceptés : jpeg, jpg, png, pdf, gif, Taille max. des fichiers : 128 MB.

Special travel requests (aisle, window...)

PRE COURSE CONGRESS

Do you want to participate to one of the Pre-Congress Course*

Yes

No

Pre-Congress Courses*

Pre-Congress Course : AUB - 50€

Pre-Congress Course : Imaging - 50€

Pre-Congress Course : Endometriosis - 50€

INVOICE ADDRESS

SOCIAL PROGRAM

Gala dinner*
Yes, I take part to the gala dinner
I will be accompanied by one person (65€)
No, I do not take part to the gala dinner
65€/person. 8:30 PM. Place to be confirmed.

INVOICE ADDRESS

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