Registration form e/MTIC course Clinical Regulatory 2025 Required fields are marked with an asterisk (*) Courseregistration (e/MTIC related only) 1/2-day course* [14-17 hrs] Date: Tuesday,聽March 25, 2025 Personal data Surname (family name)* Insertion-1 Insertion-2 Firstname* Initials* Title Gender* M F Telephone number (preferably mobile in case of last minute changes in program)*Contact data E-mail* Name hospital/company/institution* Street and number hospital/company/institution* Postalcode and + city of hospital/company/institution* Position* Department* I am in training as e/MTIC Cardiovascular e/MTIC Neuro e/MTIC Oncology e/MTIC Perinatal e/MTIC Sleep e/MTIC Other or else e/MTIC other Else If e/MTIC other or else, please write down your field of training Billing In case of a no show, we will bill you 鈧� 50. Send the bill to* Homeaddress Hospital/company/institution 果冻传媒 (I am a CI/QME/PhD trainee/eMTIC)* Costcenter and Activity number obligatory Costcenter/Projectnumber/Activitynumer/Ordernumber/reference number (with homeaddress-not applicable) 果冻传媒 trainees: please also fill in your Costcenter and project or activitynumbers. Thank You!*Course expectations What do I expect from this course (day)?*Attention: After 'submit', click on 'verzenden/send'. If you have not received a confirmation of registration by email please check your SPAM folder and notify smpee@tue.nl directly. Thank you! Don't fill this field!