UTT Workshop Registration Form

 

Event Date: July 2-4, 2017 

Event Location: Azerbaijan Medical University, Baku

 

E-mail *

Please select from the following options * SIU MemberSIU Academy MemberNon-Member

SIU Membership Number

Date of birth (mm/dd/yy) *

First Name(s) *

Last Name *

Institution *

Address line 1 *

Address line 2

City *

State/County/Province

Zip/Postal code *

Country/Region *

Work Phone

Extension

Area of Specialty/Interest * Pediatric UrologyAndrologyOncologyDiagnostic UrologyTransplantationBPHStone DiseaseIncontinenceTrauma/ReconstructionOther

Specialty *

Are you a resident/trainee? * YesNo

 * I hereby certify that the information entered is true and correct to the best of my knowledge

 * I certify that I am a healthcare provider and/or a healthcare industry professional

I give my consent to the Société Internationale d’Urologie (SIU) to share my personal data with Karl Storz SE & Co. KG, the sponsor of the eGrand Rounds. Karl Storz SE & Co. KG may use my personal data to provide me with information on their products, educational activities, customer support programmes, and survey requests.
I can revoke my consent at any time without stating any reasons by sending an email to [email protected].
By clicking the consent button, I acknowledge and agree that my personal data will be processes according to the Karl Storz privacy policy. For further details on data protection at Karl Storz SE & Co. KG. Please visit the Data protection section at www.karlstorz.com.

To receive the latest news and update on all SIU Activities, including more free eLearning programmes, please subscribe here.