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SCIENTIFIC DIRECTORS
SCIENTIFIC PROGRAMME
FACULTY FORM
ONLINE REGISTRATION
FACULTY
GENERAL INFORMATION
CONGRESS VENUE
ACKNOWLEDGMENT
ABOUT BOLOGNA
HOW TO REACH BOLOGNA
PROVIDER CME

HOME
SCIENTIFIC DIRECTORS
SCIENTIFIC PROGRAMME
FACULTY FORM
ONLINE REGISTRATION
FACULTY
GENERAL INFORMATION
CONGRESS VENUE
ACKNOWLEDGMENT
ABOUT BOLOGNA
HOW TO REACH BOLOGNA
PROVIDER CME

FACULTY FORM40rt42023-09-10T14:38:53+02:00

FACULTY FORM

We kindly ask you to fill-in the following Faculty Form to confirm your attendance.

"*" indicates required fields

General Information

Academic Title*

First Name*

Last Name*

Department*

Institution*

Address*

Town/City*

Postal/ZIP Code*

Country*

Mobile Phone*

Email*

Passport Number

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E-mail*

I hereby declare that*

I do not have an affiliation (financial or otherwise) with a pharmaceutical, medical device organization. Speakers who have no involvement with industry should inform the audience that they cannot identify any conflict of interest.

I have/had an affiliation (financial or otherwise) with a pharmaceutical, medical device organization. Complete the section below as it applies to you during the past two years.

Affiliations

Please indicate the commercial organization(s) with which you have/had affiliations, and briefly explain what connection you have/had with the organization. You must disclose this information to the audience.

Speaker Profile

Short Professional Biography*

Speaker Photo

Please submit a head shot photo to accompany your bio. The minimum dimension of your photo should be 500x500 pixel.

Accepted file types: jpeg, jpg, png, pdf, Max. file size: 50 MB.

Accommodation at Royal Hotel Carlton

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Year

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Travel Schedule

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Outbound Trip

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Return Trip

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Dietary Requirements

Please let us know if you have any particular dietary requirements:

Dietary Requirements

Vegeterian Menu

Gluten Free Menu

Low Fat Menu

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Privacy and Treatment of Personal Data

Consent*

I have read the Privacy Policy and consent to the use of my personal data for the purposes specified therein.

Terms of Participation

Terms of Participation*

The personal data you provide will be used to register you for this event.

Yes, I understand that my information will be processed and shared with the aforementioned parties in order to process my registration.

No, I do not want my information processed and shared with the aforementioned parties and understand I will not be registered.

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SCIENTIFIC DIRECTORS

Prof. Mauro Gargiulo
Prof. GianLuca Faggioli
Unit of Vascular Surgery
DIMEC University of Bologna
IRCCS S. Orsola University Hospital
Bologna (Italy)

ORGANISING SECRETARIAT

FC EVENTI SRL
Via Santo Stefano, 42 - 40125 Bologna
Tel. +39 051.236895
Fax +39 051.2916933
info@fc-eventi.com
www.fc-eventi.com

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