IATSIC International Association for Trauma Surgery and Intensive Care

* Family Name

* Given Name

Middle Name

* Gender Male
Female

* Birth Date (dd.mm.yyyy)

* Title

* Address 1

Address 2

* City

State / Province

* Postal Code

* Country

* Nationality

Phone Private

Phone Hospital

Fax

* E-mail

* Name and Titles on Diploma

* Medical Schools

* Degrees

* Present Position

* Main Hospital Affiliation (only 1)

* City of Hospital

Please list your specific fields of interest (in decreasing order of priority)

* Specific Field 1

Specific Field 2

Specific Field 3

* Main National Surgical Societies to which you belong

Please list two Sponsors (must be IATSIC Members)

* Sponsor 1 Name

* Sponsor 1 E-mail

* Sponsor 2 Name

* Sponsor 2 E-mail

Submit your Curriculum Vitae and List of Publications (mandatory), Portrait Picture (optional). Each file is limited to 500 KB.

Attachment 1

Attachment 2

Attachment 3

Comments

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