Conference

UNDIAGNOSED RARE DISEASES:
A JOINT ITALY-USA PROJECT

ISTITUTO SUPERIORE DI SANITA’

AULA POCCHIARI
Rome, Italy
November 20, 2017

1 - PERSONAL DETAILS:

First name:

Question Title

* First name:

Family name:

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* Family name:

Date of birth (mm/dd/yyyy)

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* Date of birth (mm/dd/yyyy)

Date

Country of birth:

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* Country of birth:

City of birth

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* City of birth

Gender:

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* Gender:

Male

Female

2 - PROFESSIONAL DETAILS:

Qualification:

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* Qualification:

Organisation/Company:

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* Organisation/Company:

3 - CONTACT

Address:

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* Address:

City/Town:

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* City/Town:

ZIP/Postal Code

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* ZIP/Postal Code

Phone number:

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* Phone number:

Email:

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* Email:

Contact details will be used by conferenceTechnical Secretariat

4 - POSITION

Organisation/Company activity (Public health organization, University, etc.):

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* Organisation/Company activity (Public health organization, University, etc.):

Charge:

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* Charge:

Permanent position:

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* Permanent position:

(Information according to D.Lgs. 196/2003)

INFORMATION COLLECTED ON THIS FORM WILL BE HELD IN ACCORDANCE TO THE D.LGS. 196/2003 FOR THE PURPOSES OF PROCESSING YOUR APPLICATION AND FOR PARTICIPANT ADMINISTRATION. IT WILL BE HELD SECURELY AND NOT PASSED ON TO THIRD PARTIES. ACCORDING TO THE ART. 13 OF THE ABOVE MENTIONED LAW, YOU HAVE THE RIGHT TO ASK FOR THE AMENDMENT OR CANCELLATION OF YOUR DATA.

I.S.S. - ISTITUTO SUPERIORE DI SANITÀ IS RESPONSIBLE FOR THE DATA HANDLING AND PROCESSING.

Question Title

* (Information according to D.Lgs. 196/2003)

INFORMATION COLLECTED ON THIS FORM WILL BE HELD IN ACCORDANCE TO THE D.LGS. 196/2003 FOR THE PURPOSES OF PROCESSING YOUR APPLICATION AND FOR PARTICIPANT ADMINISTRATION. IT WILL BE HELD SECURELY AND NOT PASSED ON TO THIRD PARTIES. ACCORDING TO THE ART. 13 OF THE ABOVE MENTIONED LAW, YOU HAVE THE RIGHT TO ASK FOR THE AMENDMENT OR CANCELLATION OF YOUR DATA.

I.S.S. - ISTITUTO SUPERIORE DI SANITÀ IS RESPONSIBLE FOR THE DATA HANDLING AND PROCESSING.

	Yes
I Accept	I Accept Yes