Faculty Form

Faculty Form - Smart

14091

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NAME*

First name

Family name

MOBILE*

HOME ADDRESS*

Street Address City State / Province / Region Postal / Zip Code Country

AFFILIATION*

PROFESSIONAL DATA*

Role & Department Hospital/Istitution City Country

We ask for your authorization to publish your Short Profile and Personal Photo on all SMART Meeting web-communication channels.

Authorize

Agree

Disagree

Date

Signature*

Your Short profile

Upload your Professional Photo

Twitter account

Word Verification

SMART – ORGANIZING AND SCIENTIFIC COMMITTEE

SMART ORGANIZING SECRETARIAT

PROVIDER ECM

EMERGENCY