Please note that places on the course are limited. A maximum number of 30 participants will be admitted. A confirmation of admittance will be sent by email only to the accepted applicants on September 27, 2018.

Accepted participants should come with their own laptop.

1 - PERSONAL DATA:
Name:

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* 1. Name:

Family name:

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* 2. Family name:

Date of birth

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* 3. Date of birth

Data
Place of birth:

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* 4. Place of birth:

Country:

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* 5. Country:

Gender:

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* 6. Gender:

Address:

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* 7. Address:

City:

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* 8. City:

ZIP Code:

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* 9. ZIP Code:

E-mail:

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* 10. E-mail:

2 - PROFESSIONAL DETAILS
Qualification (please specify the type of deegre):

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* 11. Qualification (please specify the type of deegre):

Please specify your professional position:

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* 12. Please specify your professional position:

Work Institution:

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* 13. Work Institution:

Type of Institution (e.g. hospital, university)

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* 14. Type of Institution (e.g. hospital, university)

Professional qualification (e.g. professor, MD):

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* 15. Professional qualification (e.g. professor, MD):

3 - OTHER INFORMATION
My tasks and my activities are:

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* 16. My tasks and my activities are:

My previous experiences and knowledge related to the course are:

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* 17. My previous experiences and knowledge related to the course are:

Taking part in the course will be useful for the following reasons:

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* 18. Taking part in the course will be useful for the following reasons:

DISCLOSURE PURSUANT TO EU REGULATION 2016/679
We inform you that the collected data will be processed and stored correctly and used exclusively for organizational and administrative purposes concerning your participation in the training event you are applying in . The data will be not object of communication or dissemination. At any time you have the right to exercise the rights provided by the Regulations, in particular ask for correction, integration or cancellation from the database. We also inform you that the data controller is the Istituto Superiore di Sanità.

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* 19. DISCLOSURE PURSUANT TO EU REGULATION 2016/679
We inform you that the collected data will be processed and stored correctly and used exclusively for organizational and administrative purposes concerning your participation in the training event you are applying in . The data will be not object of communication or dissemination. At any time you have the right to exercise the rights provided by the Regulations, in particular ask for correction, integration or cancellation from the database. We also inform you that the data controller is the Istituto Superiore di Sanità.

  Si
I accept

T