Application form for MPWB Awards For Virtual Access to AAPM 66th annual meeting 2024
By filling this form, Applicant and Head of Department/Supervisor hereby affirm and certify that the above information is complete, true, and correct. Both parties understand that any misrepresentation or falsification will result in registration cancellation and restriction from attendance at future AAPM events. After the meeting (within 2 month) the applicant is expected to submit to MPWB a short resume on how the attendance of the meeting has helped in their work or their career. 
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Name *
Registration E-mail *
Country of Residence
 *
Education (University, degree obtained, graduation year): 
 *
Work experience as a Medical Physicist *

Are you a member of MPWB?

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Name of your work Institution *
Address of your work Institution *
Name of the Departmental Head or Supervisor *
E-mail of the Departmental Head or Supervisor *
Motivation (at least 100 words) *
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