1 - PERSONAL DETAILS:

* First name:

* Family name:

* Date of birth (mm/dd/yyyy)

Date
/
/

* Country of birth:

* City of birth

* Gender:

2 - PROFESSIONAL DETAILS:

* Qualification:

* Organisation/Company:

3 - CONTACT

* Address:

* City/Town:

* ZIP/Postal Code

* Phone number:

* Email:

Contact details will be used by conferenceTechnical Secretariat
4 - POSITION

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

* Charge:

* 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.

  Yes
I Accept

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