Focused Echo for ED physicians & Intensivists Workshop Registration

Designation
---ConsultantPG traineeMedical OfficerNursing Sister / OfficerOther

Surname (Last Name) (IN BLOCK LETTERS - as it should appear in the certificate)

First name / Initials (IN BLOCK LETTERS - as it should appear in the certificate, Please type the initials if more than 15 characters in the name)

NIC number / Passport number

Contact number

Email address PLEASE TYPE IN THE EMAIL ADDRESS CORRECTLY(as one word with no spaces in between) AS THE COMMUNICATION BEYOND THIS WILL BE VIA THE EMAIL ADDRESS YOU GIVE HERE. PLEASE DO NOT DUPLICATE THE EMAIL ADDRESS FOR ANOTHER REGISTRANT, AS EMAILS YOU RECEIVE WILL HAVE NO NAMES OF APPLICANTS WHEN WE REPLY. SAME APPLICANT CAN USE IT FOR DIFFERENT WORKSHOPS/CONFERENCE.

Country of origin

Hospital / Institution attached to

Unit / Department attached to

Experience in Emergency/Critical Care (number of years)

Meal Type
VegetarianNon vegetarian

SSCCEM/ SSCCN Life Member