1st Interactive School COST ACTION 23146 - Application Form

General approach to vascular liver diseases – from diagnosis to treatment

Name

First

Last

Date of Birth

Gender

Nationality

Country of practice

Institution / Hospital

Professional Title / Position

Department / SpecialtyCheckboxes

(Top Date apply

Years of Clinical/Research Experience

Phone

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Brief description of your practice or research focus related to vascular liver disorders

Max 200 words

Why do you want to attend this course?

Max 300 words

How do you plan to apply the knowledge gained?

Max 200 words

Do you have publications or research related to vascular liver disorders?

Any special needs or accommodations required?

I certify that all information provided is accurate. I agree to abide by the course conditions.

1st Interactive School COST ACTION 23146 – Application Form