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EACTM 2024 Application Form
The course will be held January 15th-26th 2024. Please fill out all of the questions below:
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* Indicates required question
First Name
*
Your answer
Last Name
*
Your answer
Degree
*
Your answer
Degree Completion
*
Completed
In Progress
Required
Medical Specialty
*
Your answer
Address
*
Your answer
City
*
Your answer
State
Your answer
Country
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Office Phone
Your answer
Home Phone
Your answer
Mobile Phone
*
Your answer
Fax Number
Your answer
Primary Email Address
*
Your answer
Secondary Email Address
Your answer
Organization/Institution you are associated with:
Your answer
Do you qualify for a reduced rate?
Clinicians living and working in low/lower middle income countries as defined by the World Bank -
http://data.worldbank.org/about/country-and-lending-groups
Yes
No
Brief statement
*
Submit a brief statement describing your background in tropical medicine and/or infectious disease, as well as a paragraph about why you think this course will be of value to you (maximum 500 words):
Your answer
What is your experience with Ultrasound?
None
Beginner
Some Clinical Experience
Use it Often
Expert
Clear selection
Did you submit your resume and/or curriculum vitae?
*
Email your resume and/or curriculum vitae to
radic011@umn.edu
.
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No
Required
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