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FORMULAR DE INREGISTRARE INDIVIDUALA / INDIVIDUAL REGISTRATION FORM
Pentru a primi informatii actualizate despre congres, va rugam completati corect datele pentru inregistrare.
To receive updates about the congress, please fill in properly all the form fields.

Atentie! Campurile marcate cu * sunt obligatorii.
Important! All fields marqued with * are mandatory.


INFORMATII NECESARE PENTRU INSCRIEREA LA CONGRES / INFORMATION NECESSARY FOR CONGRESS REGISTRATION
Prenume / First name *
Nume / Last name *
Cod Unic de Identificare al Medicului pentru medicii membri ai CMR
In cazul in care nu sunteti membru CMR, diploma de participare nu va avea puncte EMC.

Particip in calitate de / I attend the workshop as *
Congres / Congress
Taxa de participare / Attendance fee
DATE PERSONALE DE CONTACT / PERSONAL CONTACT INFORMATION
Oras / City *
Judet / State *
Tara / Country
E-mail / E-mail *
Telefon / Phone *
DATE DESPRE INSTITUTIE / WORK CONTACT INFORMATION
Institutie / Institution *
Departament / Department *
Adresa / Address *
Oras / City *
Judet / State *
Tara / Country
E-mail / E-mail
Telefon / Phone *
DATE DE AUTENTIFICARE / LOGIN INFORMATION
Nume utilizator / Username *
Parola / Password *
Reintroduceti parola / Password confirmation *